Hot in CHEST June 2017
By: Dr. Deep Ramachandran
June 22, 2017
Each month, we ask Drs. Chris Carroll and Deep Ramachandran, Social Media Co-Editors of CHEST, to weigh in on the hot topics in CHEST. It's June, so let's hear from Dr. Ramachandran as he outlines his highlights. After reviewing the issue, be sure to share your hot list on our Facebook wall, tweet with the hashtag #journalCHEST, or discuss in the CHEST LinkedIn group.
Vitamin C: More Evidence of a Potential Cure for Sepsis
Lead author: marikpe@evms.edu
When intensivists at Sentara Norfolk General Hospital were confronted with the results of three patients with severe sepsis who were given intravenous vitamin C, they were astounded. “We have these (septic) patients, and they’re not dying,” said Dr. Marik, lead author of the study published in CHEST.
The group then began to institute intravenous vitamin C in combination with thiamine and hydrocortisone as the “standard of care” in their patients with severe sepsis. The Eastern Virginia Medical School-based group present their findings in 47 patients with sepsis treated with intravenous vitamin C, thiamine, and hydrocortisone. This treatment group was then compared with a matched group treated with usual sepsis care before the group had instituted treatment with vitamin C.
Some of the highlights from their results:
- Mean time on vasopressors: 54.9 hours in the control group vs 18.3 hours in the vitamin C group with main reduction in vasopressin use occurring 2 to 4 hours of first infusion of vitamin C (P < .001).
- 72-hour improvement in Sepsis-Related Organ Failure Assessment (SOFA) score of 4.8 in the treatment group vs 0.9 in the control group (P < .001).
- Mortality of 8.5% in the treatment group vs 40.4% in the control group (P < .001).
I feel like I need to give you a minute to digest that. Are we looking at a cure for sepsis? Why would vitamin C even be effective in sepsis? As Dr. Marik explains, it’s time that we recast our thinking of Vitamin C’s role in the body from that of nutrient to one of stress hormone. Check out this excellent editorial–it’s a must-read for anyone who wants the quick and dirty on some of vitamin C’s lesser-known functions in the body and how those mechanisms could play into its role in sepsis.
While this study has some exciting results, it leaves many questions. What is the optimal dose of vitamin C? Does it really need to be combined with steroids and thiamine? Will drug companies inevitably repackage it and charge $1,500 per dose? (Answers: ?, ?, Y). Most of these questions will need to be answered by randomized, controlled, multicenter trial(s). But clearly, these findings have made the world of critical care take notice and given caregivers and patients with sepsis something to be hopeful about.
Bonus: How did the authors get from three anecdotal cases to vitamin C being standard treatment for sepsis in their ICU?
Check out this podcast in which Dr. Marik explains how their group took the leap.
New CPT Codes for End-of-Life Discussions
Lead author: joshua.kayser@va.gov
Pulmonary physicians often deal with advanced and end-stage diagnoses. As such, they often initiate discussions with patients regarding end-of-life issues and advanced care planning. Two new CPT codes, 99497 and 99498, have been created to recognize the value of these discussions and reimburse practitioners for time spent in advance care planning.
CPT code 99497 may be used for conversations lasting from 15 to 44 minutes while CPT code 99498 is to be used for each additional 30-minute increment.
Check out the article here for further details on documentation requirements and other coding options.