(1661) Resolution of Refractory Septic Shock With High-Dose IV Hydroxocobalamin

Monday, February 24, 2025

2:30pm – 3:30pm Eastern Time

Location: Connections Central - RST 07

First Author(s)

Akshita Sahi, MD (she/her/hers)

University of Connecticut, Internal Medicine
Farmington, Connecticut, United States

Co-Author(s)

Chebly Dagher, n/a (he/him/his)

Hartford, Connecticut, USA
AS

Ashish Sharma, MD

Resident physician, Internal Medicine
University of Connecticut, United States
GF

Garrett Fiscus, DO

Fellow, Pulmonary and Critical Care Medicine
University of Connecticut, United States
AK

Antarpreet Kaur, MD

Physician, Pulmonary and Critical Care Medicine
St Francis Hospital, Trinity Health of New England, United States

Introduction: Septic shock has an estimated mortality rate of 30-40%, necessitating various therapeutic strategies for its management. Hydroxocobalamin has been investigated as an adjunctive treatment in septic shock. High-dose hydroxocobalamin can scavenge hydrogen sulfide and prevent its formation to restore vascular tone. Herein, we present a case of refractory septic shock who demonstrated rapid hemodynamic improvement after high-dose IV hydroxocobalamin.

Description: A 57-year-old male with hypertension, diabetes, heart failure, and chronic kidney disease presented with acute nausea, vomiting, and diffuse abdominal pain. He presented with hypotension refractory to aggressive fluid resuscitation. Despite prompt initiation of empiric antibiotics, the patient deteriorated requiring the sequential initiation of norepinephrine, vasopressin, phenylephrine, epinephrine, and stress-dose steroids. Diagnostic workup revealed abnormal liver function tests and cholecystitis on abdominal ultrasound reflecting septic shock. His clinical course was complicated by anuric renal failure and profound metabolic acidosis from home diuretic and metformin use. The patient received methylene blue and continuous renal replacement therapy was initiated without improvement. Five grams of intravenous hydroxocobalamin was administered with subsequent discontinuation of all vasopressors within 24 hours. A cholecystostomy tube was then placed to further facilitate resolution of the cholecystitis.

Discussion: High-dose hydroxocobalamin is associated with maintaining adequate mean arterial pressure without significant adverse effects. Case series outline that it can treat intraoperative vasoplegia during cardiopulmonary bypass and liver transplantation. A phase II clinical trial by Patel et al (CHEST, 2023) found high dose hydroxocobalamin was associated with reduced vasopressor dose in septic shock patients requiring a single vasopressor. Our patient demonstrated an immediate and sustained hemodynamic response to a single high-dose of hydroxocobalamin for septic shock on maximum vasopressor support and stress-dose steroids. It highlights that further investigation with a randomized controlled trial is warranted to assess the effect of hydroxocobalamin in septic shock.