What is the recommended dose of thiamine (Vitamin B1) for patients with septic shock?

Recommended Dose of Thiamine in Septic Shock

The recommended dose of thiamine for patients with septic shock is 200 mg intravenously every 12 hours, which has shown benefit in improving clinical outcomes and reducing vasopressor requirements. 1

Evidence for Thiamine Dosing in Septic Shock

• Current evidence supports administering thiamine at a dose of 200 mg intravenously every 12 hours in patients with septic shock 1
• This dosing regimen has demonstrated efficacy in improving lactate clearance and potentially reducing mortality in septic shock patients 2
• Thiamine administration within 24 hours of admission has been associated with improved lactate clearance and reduction in 28-day mortality compared to matched controls 2

Rationale for Thiamine Supplementation

• Septic shock is associated with thiamine deficiency in up to 70% of critically ill patients, which can impair glucose metabolism and increase oxidative stress 3
• Thiamine plays critical roles in several biological processes including metabolism of glucose, synthesis of nucleic acids, and reduction of oxidative stress 3
• Thiamine deficiency in septic shock is associated with illness severity, hyperlactatemia, and poor clinical outcomes 4

Special Considerations for Thiamine Administration

• Thiamine administration appears to be particularly beneficial in patients with confirmed thiamine deficiency (thiamine levels <8 nmol/L) 5
• In thiamine-deficient patients, supplementation is associated with higher odds of being alive and free from renal replacement therapy (adjusted odds ratio: 8.17) 5
• Thiamine administration is also associated with higher odds of survival to hospital discharge in thiamine-deficient patients (adjusted odds ratio: 6.84) 5

Combination Therapy Considerations

• Thiamine has been studied as part of a combination therapy with hydrocortisone and vitamin C in septic shock 1
• The combination of thiamine (200 mg/12h), hydrocortisone (50 mg/6h), and vitamin C (1.5g/6h) has shown promise in:
  • Reducing vasopressor dependency duration 1
  • Improving sepsis biomarkers (procalcitonin, lactate, leukocyte count) 1
  • Decreasing in-hospital mortality (10.3% vs 37.9% in control group) 1

Safety Profile and Monitoring

• Thiamine supplementation has an excellent safety profile even at high doses 3
• No significant adverse effects have been reported with thiamine administration in septic shock patients 4, 2
• Monitor lactate clearance as a marker of response to thiamine therapy 2

Pitfalls and Caveats

• While thiamine supplementation shows promise, it should be administered alongside standard septic shock management including appropriate antimicrobial therapy, fluid resuscitation, and vasopressor support 6
• The Surviving Sepsis Campaign guidelines do not specifically address thiamine supplementation as part of the core management of septic shock 6
• Caution is needed in interpreting thiamine blood concentration in critically ill patients; inflammatory status based on C-reactive protein levels should also be measured 4