1244: CAN ADMINISTRATION OF HIGH-DOSE HYDROXOCOBALAMIN IMPROVE OUTCOMES IN REFRACTORY SEPTIC SHOCK?

Abstract

Introduction: Multiple high dose vasopressors are often required to sustain life in critically ill patients but are unfortunately associated with high mortality (>50%) and morbidity. This case discusses the potential benefit in adding high dose IV hydroxocobalamin (B12) therapy (5g) to potentially reduce the use of additional vasopressors and their impact on morbidity and mortality. Description: A 72-year-old immunocompromised man with history of multiple myeloma, refractory to multiple lines of therapy, prior CAR-T treatment with now stable disease was found down, covered in feces. He was admitted to the medical ICU for severe septic shock secondary to pseudomonas bacteremia. The patient progressed to Multiorgan failure requiring mechanical ventilation, broad spectrum antibiotics, and multiple vasopressors at maximum doses. Echocardiogram (echo) showed biventricular heart failure with ejection fraction (EF) reduced from 64% 4 months prior to 25%. The bronchoalveolar lavage sample grew Pseudomonas aeruginosa, and antibiotics were adjusted. He was requiring norepinephrine (NE) at 0.3 mcg/kg/min, vasopressin (vaso) at 0.04 units/min, epinephrine (epi) to 0.3 mcg/kg/min, angiotensin II (ATII) between 10-40 ng/kg/min, and dobutamine (dobut) as high as 12.5 mcg/kg/min for 47 hours before B12 administration. The patient remained hypotensive (MAP < 65 mmHg) with maximal vasopressors. The left hand become cold and discolored, his legs and abdomen became severely mottled. Due to lack of response to therapy a trial of 5g B12 was given. There was improvement in the patient’s blood pressure. NE and ATII were stopped within 24 hours, Epi and vaso stopped within 96 hours, and dobut was weaned gradually. He was extubated on day 12. EF improved to 60% with normal right ventricular function on day 14. The skin gradually returned to normal. The left-hand fingers appeared better perfused with only the tip remaining discolored. Discussion: Bacterial endotoxins released in sepsis induce nitric oxide synthase, activating cGMP, which causes subsequent smooth muscle inhibition and vasodilation. B12 scavenges nitric oxide decreasing vasodilation. Use of B12 as an adjuvant to traditional vasopressor therapy could help reduce morbidity and mortality in septic shock by reducing overall dose/duration of vasopressors.