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LETTER TO THE EDITOR
Year : 2016  |  Volume : 5  |  Issue : 4  |  Page : 301-302

Ascorbic acid in septic shock


Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran

Date of Web Publication18-Oct-2016

Correspondence Address:
Hossein Khalili
Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2279-042X.192452

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How to cite this article:
Khalili H. Ascorbic acid in septic shock. J Res Pharm Pract 2016;5:301-2

How to cite this URL:
Khalili H. Ascorbic acid in septic shock. J Res Pharm Pract [serial online] 2016 [cited 2022 Dec 4];5:301-2. Available from: https://www.jrpp.net/text.asp?2016/5/4/301/192452

Dear Editor,

Regarding our recent published article in Journal of Research in Pharmacy Practice (Hosseini Zabet M, et al. Effect of high-dose Ascorbic acid on vasopressor's requirement in septic shock. J Res Pharm Pract 2016; 5(2):94-100), I would like to explain some points:

Sepsis is a leading cause of mortality in critically ill patients. Most patients with severe sepsis or septic shock almost always require vasoactive agents to maintain vital organs perfusion.[1] Reduced response to the available vasopressors has been proposed in these life-threatening conditions.[2],[3]

Potential benefits of Vitamin C as a potent antioxidant were evaluated in several populations of critically ill patients. In some of the studies, Vitamin C improved vasopressors responses.[4],[5],[6] Carr et al. recently collected the available evidence and proposed ascorbate-dependent vasopressor synthesis as the main mechanism for Vitamin C in severe sepsis and septic shock. This review was published in November 2015 at Journal of “Critical Care.”[7]

Most available evidence regarding the role of Vitamin C in severe sepsis and septic shock came from nonsurgical critically ill populations.[4],[5],[6] Evaluating the effect of high-dose Vitamin C in reducing vasopressor requirement in septic shock in surgical critically ill patients was registered as a Pharm D student thesis at November 17, 2014, in Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (ID: 93/d/230/4311). The results of this project were presented and approved on May 14, 2016 (ID registration: 5436). The results were also published in Journal of Research in Pharmacy Practice 2016.[8]

In this study, high-dose Vitamin C significantly reduced vasopressor requirement in surgical critically ill patients. This study was a pilot clinical study. In the published article,[8] authors mentioned mechanisms that have been proposed previously by Carr et al.[7] and others [4],[6] for the probable role of Vitamin C in severe sepsis and septic shock, including antioxidant and anti-inflammatory properties of Vitamin C, cortisol sparing effect, inhibitory effect on nitric oxide synthase and increasing catecholamines synthesis in the brain and adrenal medulla.

In drafting of our very recent article,[8] related original articles were referred to, but the review article of Carr et al.[7] was missed. This article also should have been cited for paragraph numbers 3, 4, 6, and 7 in our study.[8] Hereby, we thank them for their comprehensive review article, which regrettably was missed to acknowledge properly in our article.

However, there are several gaps regarding the definite role of Vitamin C in severe sepsis and septic shock. The optimum time for adding Vitamin C, dose of Vitamin C, method of administration (bolus or continuous infusion), vasopressors' dependent response and different critically ill populations with severe sepsis and septic shock may be considered in future studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.  Back to cited text no. 1
    
2.
O'Brien A, Clapp L, Singer M. Terlipressin for norepinephrine- resistant septic shock. Lancet 2002;359:1209-10.  Back to cited text no. 2
    
3.
Petros A, Bennett D, Vallance P. Effect of nitric oxide synthase inhibitors on hypotension in patients with septic shock. Lancet 1991;338:1557-8.  Back to cited text no. 3
    
4.
Wilson JX. Evaluation of Vitamin C for adjuvant sepsis therapy. Antioxid Redox Signal 2013;19:2129-40.  Back to cited text no. 4
    
5.
Nooraee N, Fathi M, Edalat L, Behnaz F, Mohajerani SA, Dabbagh A. Effect of Vitamin C on serum cortisol reduction after etomidate induction of anesthesia. J Cell Mol Anesth 2015;1:28-33.  Back to cited text no. 5
    
6.
May JM, Qu ZC, Nazarewicz R, Dikalov S. Ascorbic acid efficiently enhances neuronal synthesis of norepinephrine from dopamine. Brain Res Bull 2013;90:35-42.  Back to cited text no. 6
    
7.
Carr AC, Shaw GM, Fowler AA, Natarajan R. Ascorbate-dependent vasopressor synthesis: A rationale for Vitamin C administration in severe sepsis and septic shock? Crit Care 2015;19:418.  Back to cited text no. 7
    
8.
Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose ascorbic acid on vasopressor's requirement in septic shock. J Res Pharm Pract 2016;5:94-100.  Back to cited text no. 8
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