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ICU Vitamin D injection (300,000 IU) helped - RCT Feb 2021


High dose vitamin D improves total serum antioxidant capacity and ICU outcome in critically ill patients - A randomized, double-blind clinical trial

European Journal of Integrative Medicine Volume 42, February 2021, https://doi.org/10.1016/j.eujim.2020.101271
Mohammad Sistanizad a b, Mehran Kouchek c, MirMohammad Miri c, Sara Salarian c, Seyedpouzhia Shojaei c, Fatemeh Moeini Vasegh a, Hossein Seifi Kafshgari d, Roja Qobadighadikolaei e

Abstract
Introduction
Mechanical ventilation can increase the rate of free radicals in the systemic circulation due to its effect on the inflammatory system. Previous research has suggested that vitamin D has antioxidant properties. This study aimed to evaluate the effect of vitamin D on total Antioxidant Capacity (TAC) and its relationship with ICU patients' outcomes.

Methods
In this prospective randomized clinical trial, 36 ventilated ICU patients were randomly allocated to receive either a single intramuscular vitamin D 300,000 IU or its placebo. Serum Vitamin D and TAC were measured before and on day 7 after the intervention. Clinical Pulmonary Infection Score (CPIS) and sequential organ failure assessment (SOFA) scores were measured daily for seven days and on days 14 and 28.

Results
Thirty patients completed the study. The results show that injection of vitamin D leads to a significant increase in the

  • mean changes of vitamin D level on the seventh day of the study (+3.5±1.3 vs -0.4±0.2 P=0.00) and
  • TAC levels (3.2±3.9 vs -2.0±2.6 P=0.00.
  • ICU length of stay was 18.3±8.4 and 25.4±6.6 days in the intervention and placebo arms of the study.

Twelve patients in the placebo group and 5 in the vitamin D group died within the 28 day study period. The duration of mechanical ventilation was 15.7± 9.3 vs. 22.6± 9.1 days in vitamin D and placebo arms, respectively.

Conclusion
Administration of vitamin D may increase TAC levels and decrease the length of stay and duration of mechanical ventilation in ICU patients.

Introduction
Vitamin D is a fat-soluble vitamin acting by its metabolite 1,25-dihydroxy vitamin D3, and it has more substantial effects on various metabolic activities than initially anticipated [1], [2], [3]. A multitude of new studies has shown numerous biological effects of vitamin D on the modulation of bone as well as muscle metabolism. In addition to these known effects, vitamin D also plays an important role in immune function and cardiovascular modulation effects which may be required for the evolution of recovery from critical illness [2,[[4], [5], [[6]].

Vitamin D deficiency is widespread among all age groups. Furthermore, almost one billion adults in the world are vitamin D deficient [7]. Moreover, Vitamin D deficiency has been detected in 40% to 70% of critically ill patients [2,[[8], [9], [[10]].

Multiple studies have also indicated that vitamin D deficiency can cause greater illness severity, morbidity, and mortality [11], [12], [13]. The daily recommended low-dose administration of vitamin D (400 to 4000 IU daily) cannot quickly reinstate 25 hydroxyvitamin D levels in acutely ill patients [14], besides that recent studies have also shown that higher bolus doses of vitamin D (single loading dose from 50,000 to 600,000 IU) can restore 25 hydroxyvitamin D levels rapidly and safely in the acutely ill patients [15], [16], [17], [18]. However, the correlation between vitamin D deficiency and its replacement, the severity of the disease, mortality, and length of hospital stay in critically ill patients remains controversial. Some studies revealed no correlation [9,10,19]. In contrast, several meta-analyses have also reported that patients with low vitamin D levels have more extended ICU stays and higher morbidity and mortality [8,13,20]. Also, the relationship between vitamin D deficiency and the severity of the disease has been demonstrated in some other studies. However, vitamin D's connection to prolonged duration of ICU stay, increased prevalence of renal failure, and sepsis has not been confirmed [10,18,19].

Moreover, a current study showed that vitamin D acts as an antioxidant throughout the expression of multiple molecules included in the antioxidant defense system such as glutathione (GSH), superoxide dismutase (SOD), and GSH peroxidase superoxide dismutase. Furthermore, vitamin D represses the expression of NADPH (nicotinamide adenine dinucleotide phosphate) oxidase [21].

Despite several trials being conducted on the effect of vitamin D in critically ill patients, there have been insufficient studies to assess the association between the plasma concentration of 25-OH Vitamin D, oxidative system markers, ICU length of stay, and duration of mechanical ventilation in ventilated ICU patients. Therefore, the principal goal of the current clinical trial was to evaluate the effect of vitamin D supplementation on total antioxidant capacity in intubated critically ill patients. More, as secondary objectives, we evaluated the effect of single high dose vitamin D administration on the patient's duration of mechanical ventilation and length of ICU stay. Furthermore, the aforementioned steps were performed to determine patients' ICU outcomes and also to pinpoint the relationship between TAC and ICU outcomes.

Section snippets
Study design
The present study was a randomized, placebo-controlled, single-center, double-blinded clinical trial that was conducted on ventilated ICU patients admitted to the ICU of Imam Hussein Hospital after acceptance by the ethics committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran (1397.12.IR.SBMU.PHNM) and registration and approval by Iranian Clinical Trial Registry (IRCT) with code of IRCT20120703010178N16.

Entry criteria: The patients were selected using convenience sampling and recruited into . . .

Results
A total of 64 ventilated patients were admitted into the ICU between September 2019 and March 2020 and were evaluated based on the defined inclusion criteria. Based on the inclusion/exclusion criteria, 28 subjects were excluded and the remaining patients were recruited. After randomization into two groups, 20 patients were allocated to the Vitamin D (intervention) group and 16 patients were allocated to the control group. A further six patients were excluded during follow up and 30 patients . . .

Vitamin D level
Measurement of vitamin D levels on the seventh day of the study indicated an increase from 7.3 ± 2.3 to 11.1 ± 3.7 (ng/dL) in the Vitamin D group (P-value = 0.00) and a decrease from 5.24 ± 0.7 to 4.8 ± 0.9 (ng/dL) in the placebo group (P-value =0.34). The mean difference between the two groups was also significant (P-value =0.00). Data are shown in Table 2. . . .
Note by VitaminDWiki - Vitamin D levels increased 73 ng/ml in 7 days

Discussion
Most critically ill patients demonstrate oxidative imbalance. Furthermore, by considering lower TAC values in critically ill patients [24], the critical role of free radicals in increasing the duration of mechanical ventilation, complications due to infections, and longer length of hospital stays becomes clear. However, the fact that vitamin D might be a powerful tool against the mentioned detrimental pathways, the current study aimed at comparing the effect of vitamin D on total antioxidant . . .

Conclusion
In conclusion, the results of this research supported the idea that the administration of high-dose vitamin D could be a powerful tool in reducing the duration of mechanical ventilation, the duration of hospitalization, and mortality rate. These beneficial effects could be explained by the effect of vitamin D on increasing TAC blood levels in ICU patients. Considering the current COVID 19 crisis and its effect on oxidative stress, these findings also could be relevant for patients suffering . . .


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