• Jayshil J Patel, Rodney Willoughby, Jennifer Peterson, Thomas Carver, James Zelten, Adrienne Markiewicz, Kaitlin Spiegelhoff, Lauren A Hipp, Bethany Canales, Aniko Szabo, Daren K Heyland, Christian Stoppe, Jacek Zielonka, and Julie K Freed.
• Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin. Electronic address: jpate12@mcw.edu.
• Chest. 2023 Feb 1; 163 (2): 303312303-312.

BackgroundElevated hydrogen sulfide (H2S) contributes to vasodilatation and hypotension in septic shock, and traditional therapies do not target this pathophysiologic mechanism. High-dose IV hydroxocobalamin scavenges and prevents H2S formation, which may restore vascular tone and may accentuate recovery. No experimental human studies have tested high-dose IV hydroxocobalamin in adults with septic shock.Research QuestionIn adults with septic shock, is comparing high-dose IV hydroxocobalamin with placebo feasible?Study Design And MethodsWe conducted a phase 2 single-center, double-blind, allocation-concealed, placebo-controlled, parallel-group pilot randomized controlled trial comparing high-dose IV hydroxocobalamin with placebo in critically ill adults with septic shock. Patients meeting Sepsis 3 criteria were randomized 1:1 to receive a single 5-g dose of high-dose IV hydroxocobalamin or equivalent volume 0.9% saline solution as placebo. The primary outcome was study feasibility (enrollment rate, clinical and laboratory compliance rate, and contamination rate). Secondary outcomes included between-group differences in plasma H2S concentrations and vasopressor dose before and after infusion.ResultsTwenty patients were enrolled over 19 months, establishing an enrollment rate of 1.05 patients per month. Protocol adherence rates were 100% with zero contamination. In the high-dose IV hydroxocobalamin group, compared to placebo, there was a greater reduction in vasopressor dose between randomization and postinfusion (-36% vs 4%, P < .001) and randomization and 3-h postinfusion (-28% vs 10%, P = .019). In the high-dose IV hydroxocobalamin group, the plasma H2S level was reduced over 45 mins by -0.80 ± 1.73 μM, as compared with -0.21 ± 0.64 μM in the placebo group (P = .3).InterpretationThis pilot trial established favorable feasibility metrics. Consistent with the proposed mechanism of benefit, high-dose IV hydroxocobalamin compared with placebo was associated with reduced vasopressor dose and H2S levels at all time points and without serious adverse events. These data provide the first proof of concept for feasibility of delivering high-dose IV hydroxocobalamin in septic shock.Trial RegistryClinicalTrials.gov; No.: NCT03783091; URL: www.Clinicaltrialsgov.Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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