Why Are so Many COVID Patients Dying of Sepsis?
- July 21, 2020
Story at-a-glance
- In July 2020, famous Broadway actor Nick Cordero died of complications from COVID-19, including septic shock, or sepsis
- Sepsis is a leading cause of deaths overall, and it’s also an important contributor to the death of COVID-19 patients — one that’s been flying largely under the radar
- The symptoms of sepsis may be confused with those from a bad cold or the flu, and include high fever, chills, confusion, rapid heartbeat, nausea or vomiting and cold, clammy skin
- A sepsis treatment protocol developed by Dr. Paul Marik, which involves intravenous vitamin C with hydrocortisone and thiamine (vitamin B1), has been shown to dramatically improve chances of survival in sepsis cases
In July 2020, famous Broadway actor Nick Cordero died of complications from COVID-19, including septic shock, or sepsis.1
Sepsis is a life-threatening condition triggered by a systemic
infection that causes your body to overreact and launch an excessive and
highly damaging immune response. Unless promptly diagnosed and treated,
it can rapidly progress to multiple-organ failure and death.
Sepsis is common, affecting at least 1.7 million Americans every year and leading to 270,000 deaths. In hospitals, 1 in 3 patients who die have sepsis, according to the U.S. Centers for Disease Control and Prevention,2 and it’s a major contributing factor to influenza deaths.3
Not only is sepsis a leading cause of deaths overall, it’s also an important contributor to the death of COVID-19 patients — one that’s been flying largely under the radar.
Viral sepsis can be particularly challenging, according to the Sepsis Alliance, because tests that reveal bacterial sepsis to physicians do not necessarily reveal viral sepsis. That being said, abnormal vital signs, including blood pressure, pulse and respirations, may occur with either bacterial or viral sepsis.
Dr. Karin Molander, chair of the Sepsis Alliance board of directors, explained, “Studies coming out of Wuhan, China, and our experts here in the U.S. are finding that sepsis is a leading, if not the number one, fatal complication of COVID-19.”5 Sepsis occurs so often alongside COVID-19 that the National Center for Health Statistics released updated guidelines for medical coding of the two conditions.6
In a Q&A by the Association of Clinical Documentation Integrity Specialists (ACDIS) Leadership Exchange, a commentator asked, “I’m not clear if we still follow sequencing direction included in the Official Guidelines for Coding and Reporting which states that we should code first for sepsis followed by infection. This would make more sense to me …”7
In response, ACDIS noted, “When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations …”
The updated guidelines suggest that whether or not coding for COVID-19 or sepsis occurs first depends on their sequencing (if the patient has sepsis upon hospital admission or developed it after admission, for instance).8
Because people requiring home health care are at increased risk for COVID-19 and other infections, as well as sepsis, the Sepsis Alliance partnered with Elara Caring, a U.S. provider of home-based health care, to improve care and outcomes for COVID-19 patients with sepsis in the home care setting.10
Staff will receive increased education and training on sepsis prevention and care, which could be life-saving, since early detection and treatment can mean the difference between life and death in sepsis cases, which often start in the community from an infection caused by bacteria or a virus, parasite or fungus.
The immune response triggered by an infection may lead to leaky blood vessels, blood clots, poor blood flow and, in severe cases, organ failure.11 When blood pressure drops in combination with a weakened heart it leads to septic shock.
As mentioned, the underlying trigger, an infection, often starts in the community. This may explain why it is often misdiagnosed in the beginning, which increases the potential risk for disability and death.
While those affected often have underlying health conditions, even healthy people can be affected. “[W]hen a healthy person becomes severely ill with sepsis, it could be that their healthy immune system was so strong it triggered a cytokine storm,” the Sepsis Alliance explained.12
“Most of these severely ill patients receive treatment in an ICU or high acuity unit. There they may receive experimental medications like interleukin antibodies, such as anti-IL-1 or anti-IL-6 and high dose corticosteroids to try to get the cytokine storm under control,” according to the Sepsis Alliance.14 Natural options have also shown promise for alleviating cytokine storms, including:
As explained by Saul, vitamin C at extremely high doses acts as an antiviral drug, actually killing viruses. While it does have anti-inflammatory activity, which helps prevent the massive cytokine cascade associated with severe SARS-CoV-2 infection, its antiviral capacity likely has more to do with it being a non-rate-limited free radical scavenger.
Rhonda Patrick, Ph.D. also noted that vitamin C may be protective against respiratory diseases. In one study, people with the highest vitamin C levels were 15% less likely to develop respiratory conditions and 46% less likely to die of lung cancer compared to those with the lowest levels.19
Further, vitamin C is well known for helping with lung defense, which takes on renewed meaning in the midst of the COVID-19 pandemic. According to Patrick:20
His retrospective before-after clinical study showed that giving patients 200 milligrams (mg) of thiamine every 12 hours, 1,500 mg of ascorbic acid every six hours, and 50 mg of hydrocortisone every six hours for two days reduced mortality from 40% to 8.5%.23
“Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock,” Marik and colleagues wrote in the journal Chest.24
Research published in 2020 found Marik’s sepsis vitamin C protocol lowered mortality in pediatric patients as well.25 As noted by the authors, “Our results suggest that HAT [hydrocortisone, ascorbic acid and thiamine] therapy, when administered early in the clinical course, reduces mortality in children with septic shock.”
While each part of the protocol is safe on an individual basis, the three parts must be administered together to work effectively. Marik explained the combination targets multiple areas of the body's response to an infection and helps restore the dysregulated immune response.26
This then helps prevent organ failure and death. He goes on to discuss the excess production of reactive oxygen species underlies many of the damaging processes in sepsis. His team found the optimal dose of vitamin C was about 6 grams per day.
Sepsis is a medical emergency, so if you suspect you may have it, get
medical help immediately. Marik's sepsis protocol can be a lifesaver,
so you'd be wise to discuss it with your doctor any time you're
hospitalized.
This way, should you develop sepsis while you're admitted, your medical team already knows your wishes and can act swiftly. According to Marik, the best results are obtained when the protocol is administered within the first six hours of presentation of symptoms.28
Sepsis is common, affecting at least 1.7 million Americans every year and leading to 270,000 deaths. In hospitals, 1 in 3 patients who die have sepsis, according to the U.S. Centers for Disease Control and Prevention,2 and it’s a major contributing factor to influenza deaths.3
Not only is sepsis a leading cause of deaths overall, it’s also an important contributor to the death of COVID-19 patients — one that’s been flying largely under the radar.
Many Critically Ill COVID Patients Develop Sepsis
Researchers from China wrote in The Lancet, “In clinical practice, we noticed that many severe or critically ill COVID-19 patients developed typical clinical manifestations of shock, including cold extremities and weak peripheral pulses, even in the absence of overt hypotension. Understanding the mechanism of viral sepsis in COVID-19 is warranted for exploring better clinical care for these patients.”4Viral sepsis can be particularly challenging, according to the Sepsis Alliance, because tests that reveal bacterial sepsis to physicians do not necessarily reveal viral sepsis. That being said, abnormal vital signs, including blood pressure, pulse and respirations, may occur with either bacterial or viral sepsis.
Dr. Karin Molander, chair of the Sepsis Alliance board of directors, explained, “Studies coming out of Wuhan, China, and our experts here in the U.S. are finding that sepsis is a leading, if not the number one, fatal complication of COVID-19.”5 Sepsis occurs so often alongside COVID-19 that the National Center for Health Statistics released updated guidelines for medical coding of the two conditions.6
In a Q&A by the Association of Clinical Documentation Integrity Specialists (ACDIS) Leadership Exchange, a commentator asked, “I’m not clear if we still follow sequencing direction included in the Official Guidelines for Coding and Reporting which states that we should code first for sepsis followed by infection. This would make more sense to me …”7
In response, ACDIS noted, “When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations …”
The updated guidelines suggest that whether or not coding for COVID-19 or sepsis occurs first depends on their sequencing (if the patient has sepsis upon hospital admission or developed it after admission, for instance).8
Who’s at Risk of Sepsis?
According to Sepsis Alliance, “the elderly, very young and people with chronic illnesses or weakened immune systems” are most at risk of sepsis.9Because people requiring home health care are at increased risk for COVID-19 and other infections, as well as sepsis, the Sepsis Alliance partnered with Elara Caring, a U.S. provider of home-based health care, to improve care and outcomes for COVID-19 patients with sepsis in the home care setting.10
Staff will receive increased education and training on sepsis prevention and care, which could be life-saving, since early detection and treatment can mean the difference between life and death in sepsis cases, which often start in the community from an infection caused by bacteria or a virus, parasite or fungus.
The immune response triggered by an infection may lead to leaky blood vessels, blood clots, poor blood flow and, in severe cases, organ failure.11 When blood pressure drops in combination with a weakened heart it leads to septic shock.
As mentioned, the underlying trigger, an infection, often starts in the community. This may explain why it is often misdiagnosed in the beginning, which increases the potential risk for disability and death.
While those affected often have underlying health conditions, even healthy people can be affected. “[W]hen a healthy person becomes severely ill with sepsis, it could be that their healthy immune system was so strong it triggered a cytokine storm,” the Sepsis Alliance explained.12
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The Cytokine Storm Connection
Cytokines are a group of proteins that your body uses to control inflammation. If you have an infection, your body will release cytokines to help combat inflammation, but sometimes it releases more than it should. If the cytokine release spirals out of control, the resulting “cytokine storm” becomes dangerous and is closely tied to sepsis. Dr. Molander said:13“A deluge of chemicals can be released by white blood cells to attract additional white blood cells to fight infection or temper down the reaction if the infection appears to be under control.
These chemicals can also trigger the blood to clot or to become thinner. This cytokine storm, an important part of sepsis, can be triggered when we face an infection from a bacteria, virus, parasite or fungus. In typical years, bacteria are the most common cause of sepsis. But, alas, this is not a typical year.”The symptoms of cytokine storm are indicative of severe illness and include high fever, severe fatigue, nausea and organ failure.
“Most of these severely ill patients receive treatment in an ICU or high acuity unit. There they may receive experimental medications like interleukin antibodies, such as anti-IL-1 or anti-IL-6 and high dose corticosteroids to try to get the cytokine storm under control,” according to the Sepsis Alliance.14 Natural options have also shown promise for alleviating cytokine storms, including:
- Astaxanthin, a powerful antioxidant and anti-inflammatory agent derived from microalgae15
- The omega-3 fats docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), long-chained fats found in cold-water fatty fish like wild-caught Alaskan salmon, sardines, anchovies and krill16
- Curcumin, the active ingredient in the spice turmeric17
- Vitamin D optimization18
- Molecular hydrogen
Vitamin C Shows Promise for COVID-19, Sepsis
In my March 17, 2020, interview with Dr. Andrew Saul, editor-in-chief of the Orthomolecular Medicine News Service, Saul mentions being in contact with a South Korean medical doctor who is giving patients and medical staff an injection of 100,000 IUs of vitamin D along with as much as 24,000 mg (24 grams) of IV vitamin C. "He's reporting that these people are getting well in a matter of days," Saul says.As explained by Saul, vitamin C at extremely high doses acts as an antiviral drug, actually killing viruses. While it does have anti-inflammatory activity, which helps prevent the massive cytokine cascade associated with severe SARS-CoV-2 infection, its antiviral capacity likely has more to do with it being a non-rate-limited free radical scavenger.
Rhonda Patrick, Ph.D. also noted that vitamin C may be protective against respiratory diseases. In one study, people with the highest vitamin C levels were 15% less likely to develop respiratory conditions and 46% less likely to die of lung cancer compared to those with the lowest levels.19
Further, vitamin C is well known for helping with lung defense, which takes on renewed meaning in the midst of the COVID-19 pandemic. According to Patrick:20
“The innate immune system of the lungs is an integral component of the body's defense system, protecting the body against exposure to inhaled oxidants and pathogens … Vitamin C's lung defense capacity is evidenced by robust data suggesting that vitamin C intake protects against chronic obstructive pulmonary disease, pulmonary fibrosis, and other respiratory illnesses, including lung cancer.
But this characteristic takes on special relevance in light of recent concerns about complications associated with COVID-19, such as pneumonia and acute lung injury, which often necessitate mechanical ventilation support.
Epidemiological and observational data indicate that higher vitamin C intake is associated with a lower risk of developing pneumonia, and the vitamin has also proven to be effective at decreasing the duration for which patients are kept on mechanical ventilation, especially among patients who require more than 24 hours of breathing support.”Of note, vitamin C is also useful for sepsis. A 2019 study using vitamin C found it lowered mortality risk in patients with severe sepsis, and reduced the number of days spent in intensive care and overall hospital stay.21
Dr. Marik’s Vitamin C Protocol
A sepsis treatment protocol developed by Dr. Paul Marik, a critical care doctor at Sentara Norfolk General Hospital in East Virginia, which involves intravenous (IV) vitamin C with hydrocortisone and thiamine (vitamin B1), has been shown to dramatically improve chances of survival in sepsis cases.22His retrospective before-after clinical study showed that giving patients 200 milligrams (mg) of thiamine every 12 hours, 1,500 mg of ascorbic acid every six hours, and 50 mg of hydrocortisone every six hours for two days reduced mortality from 40% to 8.5%.23
“Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock,” Marik and colleagues wrote in the journal Chest.24
Research published in 2020 found Marik’s sepsis vitamin C protocol lowered mortality in pediatric patients as well.25 As noted by the authors, “Our results suggest that HAT [hydrocortisone, ascorbic acid and thiamine] therapy, when administered early in the clinical course, reduces mortality in children with septic shock.”
While each part of the protocol is safe on an individual basis, the three parts must be administered together to work effectively. Marik explained the combination targets multiple areas of the body's response to an infection and helps restore the dysregulated immune response.26
This then helps prevent organ failure and death. He goes on to discuss the excess production of reactive oxygen species underlies many of the damaging processes in sepsis. His team found the optimal dose of vitamin C was about 6 grams per day.
Common Signs of Sepsis
The symptoms of sepsis may be confused with those of a bad cold or flu, and include:27| A high fever with chills and shivering | Rapid heartbeat (tachycardia) |
| Rapid breathing (tachypnea) | Unusual level of sweating (diaphoresis) |
| Dizziness | Confusion or disorientation |
| Slurred speech | Diarrhea, nausea or vomiting |
| Difficulty breathing, shortness of breath | Severe muscle pain |
| Low urine output | Cold and clammy skin |
| Skin rash |
This way, should you develop sepsis while you're admitted, your medical team already knows your wishes and can act swiftly. According to Marik, the best results are obtained when the protocol is administered within the first six hours of presentation of symptoms.28
+ Sources and References
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