Many trauma patients do not survive the post-operational stage due to multiple-organ failure, but a recent study has shown that post-operational survival can be improved by antioxidant therapy.
In a study presented at the 2008 Clinical Congress of the American College of Surgeons (ACS), Bryan A. Cotton, MD, FACS, stated that “implementation of high-dose antioxidant protocol (vitamins C, E, and selenium) resulted in a reduction of pulmonary complications, in general, as well as infectious complications, including central line and catheter-related infections.”
Dr. Cotton, assistant professor of surgery at Vanderbilt University Medical Center, Nashville, TN, observed that when an abdominal wound opens up, the result is not just an infection to be treated with antibiotics. Sometimes the wounds open up, requiring reconstruction with expensive agents. Dr. Cotton observed a remarkable decrease in abdominal wall complications—including abdominal compartment syndrome and surgical site infections.
“This is a high mortality, high morbidity, may-never-return-to-work-again problem in a young healthy patient,” he said. “Abdominal wall complications are enormous, yet we noted a reduction in some of these complications with implementation of antioxidants. Importantly, the biggest difference was in those patients who had a predicted mortality exceeding 50 percent.”
Dr. Cotton and his colleagues at Vanderbilt showed that this high-dose antioxidant protocol accounted for an amazing 28% reduction in mortality in acutely injured patients. Length-of-stay, hospital and ICU, was also reduced. Dr. Cotton explained how an acute injury imposes a huge strain on the body, which releases oxygen molecules called free radicals, that cause damage at the cellular level called oxidative stress. Antioxidants work as a team in mopping up some of the oxidative stress waste byproducts, reducing the stressors that cause harm. Depletion of antioxidants is one of the mechanisms that explains why we are vulnerable. Antioxidant therapy replenishes those troops to help keep us safe.
“Antioxidant therapy is so simple and that’s what throws people off,” Dr. Cotton said. A trial conducted by Avery B. Nathens, MD, MPH, showed that some inflammatory states and responses were remarkably improved in patients who had received antioxidants versus those who did not. “Based on these results, we were inspired to initiate a study with vitamins C and E. When we looked at the literature, however, there were some concurrent studies showing that selenium had an impact too, especially on sepsis and other infectious complications. So we combined all the existing research and did a cost analysis. When we learned it would cost only $11 a patient for a seven-day course of antioxidants, we decided to give it a try.”
This retrospective study followed a total of 4,279 patients admitted to the Vanderbilt University Medical Center trauma unit during the study period. High-dose antioxidant protocol was administered to all acutely injured patients (2,258 individuals) admitted to the center between October 1, 2005, and September 30, 2006. This treatment included 1,000 mg. vitamin C (ascorbic acid) -tocopherol acetate), each routinely given everyaand 1,000 IU vitamin E (DL- eight hours by mouth, if the patient could take it that way. In addition, 200 mcg. selenium was given once daily intravenously. Patients received these supplements upon arrival, and they were continued for seven days or until discharge, whichever happened first. Patients who were pregnant or had serum creatinine levels >2.5mg/dL did not receive antioxidants.
A comparison cohort was made up of all patients (2,021 individuals) admitted to the trauma center between October 1, 2004, and September 30, 2005—prior to implementation of the antioxidant protocol. While pneumonia and renal failure were similar between the groups, the incidence of abdominal compartment syndrome was significantly less (90 versus 31), as were catheter-related infections (75 versus 50) and surgical site infections (101 versus 44). Pulmonary failure—meaning the patient could not get off the ventilator—was less as well (721 versus 528).
Dr. Cotton is now prescribing high-dose antioxidants only to the most seriously ill patients in the ICU, as they seem to derive the greatest benefit. He and his colleagues will now focus on dose adjustments and length of administration to see if the doses and duration they are currently using are optimal. They have been approached by several groups that are interested in collaborating and investigating these agents as part of multiinstitutional trials and expanding their use to critically ill nontrauma patients.
“While we are all looking for that magic bullet to cure some of the horrible things that can happen after someone is injured or has an operation, we have something at our disposal,” Dr. Cotton said. “It might not be that magic bullet, but it is a very inexpensive and safe way to reduce complications and mortality in the sickest patients.”
Assisting Dr. Cotton with this study were Aviram Giladi, BS; Bryan R. Collier, DO, FACS; Lesly A. Dossett, MD; and Sloan B. Fleming, PharmD, all from Vanderbilt. He received no funding for this research.
Source: American College of Surgeons