Vitamin C Infusion for Treatment in Sepsis Induced Acute Lung Injury

Hypothesis 1A: Vitamin C infusion will significantly attenuate sepsis-induced systemic organ failure as measured by Sequential Organ Failure Assessment (SOFA) score,

Hypothesis 1B: Vitamin C infusion will attenuate sepsis-induced lung injury as assessed by the oxygenation index and the VE40

Hypothesis 1C: Vitamin C infusion will attenuate biomarkers of inflammation (C-Reactive Protein, Procalcitonin), vascular injury (Thrombomodulin, Angiopoietin-2), alveolar epithelial injury (Receptor for Advanced Glycation Products), while inducing the onset of a fibrinolytic state (Tissue Factor Pathway Inhibitor).


Eligibility Criteria:
Inclusion Criteria:

* Patients must have suspected or proven infection, and meet 2 out of 4 of the criteria for Systemic Inflammatory Response (SIRS) due to infection, and be accompanied by at least 1 criterion for sepsis-induced organ dysfunction, and meet all 5 criteria for Acute Respiratory Distress Syndrome (ARDS).
* Suspected or proven infection: (e.g., thorax, urinary tract, abdomen, skin, sinuses, central venous catheters, and central nervous system, see Appendix A).
* The presence of a systemic inflammatory response: Defined as: fever: \>38ºC (any route) or hypothermia: \<36ºC (core temp only), tachycardia: heart rate \> 90 beats/min or receiving medications that slow heart rate or paced rhythm, leukocytosis: \>12,000 WBC/µL or leukopenia: \<4,000 WBC/µL or \>10% band forms. Respiratory rate \> 20 breaths per minute or PaCO2 \< 32 or invasive mechanical ventilation.
* The presence of sepsis associated organ dysfunction: (any of the following thought to be due to infection)
* Sepsis associated hypotension (systolic blood pressure (SBP) \< 90 mm Hg or an SBP decrease \> 40 mm Hg unexplained by other causes or use of vasopressors for blood pressure support (epinephrine, norepinephrine, dopamine =/\> 5mcg, phenylephrine, vasopressin)
* Arterial hypoxemia (PaO2/FiO2 \< 300) or supplemental O2 \> 6LPM.
* Lactate \> upper limits of normal laboratory results
* Urine output \< 0.5 ml/kg/hour for \> two hours despite adequate fluid resuscitation
* Platelet count \< 100,000 per mcL
* Coagulopathy (INR \> 1.5)
* Bilirubin \> 2 mg/dL
* Glasgow Coma Scale \< 11 or a positive CAM ICU score
* ARDS characterized by all the following criteria
* Lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms
* Bilateral opacities on chest imaging not explained by other pulmonary pathology (e.g. pleural effusions, lung collapse, or nodules)
* Respiratory failure not explained by heart failure or volume overload
* Decreased arterial PaO2/FiO2 ratio ≤ 300 mm Hg
* Minimum PEEP of 5 cmH2O (may be delivered noninvasively with CPAP to diagnose mild ARDS

Exclusion Criteria:

* Known allergy to Vitamin C
* inability to obtain consent;
* age \< 18 years;
* No indwelling venous or arterial catheter in patients requiring insulin in a manner that requires glucose being checked more than twice daily (e.g. continuous infusion, sliding scale);
* presence of diabetic ketoacidosis;
* more than 48 hrs since meeting ARDS criteria;
* patient or surrogate or physician not committed to full support (not excluded if patient would receive all supportive care except for cardiac resuscitation);
* pregnancy or breast feeding,
* moribund patient not expected to survive 24 hours;
* home mechanical ventilation (via tracheotomy or noninvasive) except for CPAP/BIPAP used only for sleep-disordered breathing;
* home O2 \> 2LPM, except for with CPAP/BIPAP
* diffuse alveolar hemorrhage (vasculitis);
* interstitial lung disease requiring continuous home oxygen therapy;
* Active kidney stone
* Non English speaking;
* Ward of the state (inmate, other)