Conditions: Sepsis Septic Shock Metabolic Disturbance
Keywords: Sepsis Metabolic Resuscitation
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 205
Healthy volunteers: no

Brief summary:
In this study, we aim to determine whether the combination of Ascorbic Acid (Vitamin C), Thiamine (Vitamin B1), and Corticosteroids improves the trajectory of organ failure and reduces mortality in patients with sepsis and septic shock as compared to placebo.

Detailed description:
Sepsis and Septic Shock are common and highly morbid clinical conditions without any specific therapy aside from antibiotics. A recent quasi-experimental study (Marik et. al., PMID 27940189) demonstrated a remarkable benefit when the combination of Ascorbic Acid (Vitamin C), Corticosteroids, and Thiamine (Vitamin B1) were given to patients with sepsis. In particular, patients who received this combination of medications required a shorter amount of time on vasopressors, suffered less organ failure, and had improved mortality. Vitamin C has long been suggested for treatment of patients with severe infection as it exerts significant anti-oxidant effects and reduces endothelial permeability. Corticosteroids, a mainstay of therapy for refractory shock in sepsis, have also been shown to enhance the beneficial cellular effects of vitamin C. Finally, thiamine has been shown to be an effective mitochondrial resuscitator in sepsis, especially for the \~30% of septic shock patients who present with thiamine deficiency (Donnino et. al, PMID 26771781).

In this study, we aim to reproduce the findings of Marik et. al. using a more rigorous study design (i.e. a blinded, randomized clinical trial) and focus on the important clinical outcomes of organ failure and death.

Arms:
arm 1: The combination of vitamin C, vitamin B1, hydrocortisone :

* Vitamin C (ascorbic acid) 1.5g every 6 hours x 4-days
* Vitamin B1 (thiamine) 100mg every 6 hours x 4-days
* Hydrocortisone 50mg every 6 hours x 4-days arm 2: Normal Saline Solution (0.9%NaCl) in a volume to match all experimental arm components

Interventions: intervention 1: vitamin C, vitamin B1, hydrocortisone intervention 2: Normal saline
Intervention descriptions: intervention 1: Vitamin C (1.5g) plus vitamin B1 (100mg) will be diluted in 100ml 0.9% NACL(normal saline) and administered IV every 6 hours for 4 days or until participant is discharged from the ICU. Hydrocortisone 50mg/ml will be administered via IV push over 1-2 minutes every 6hours for 4 days or until the patient is discharged from the ICU. intervention 2: Normal saline (0.9% NaCl solution) volume to match all components

Protocol document:
SAP_003.pdf: 
 
 
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Supplement 1: Study Protocol 
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Supplement 1 contains the ACTS clinical trial protocol v2.4. In addition, the published clinical trial 
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protocol and statistical analysis plan can be found: Moskowitz A, Yankama T, Andersen LW for the 
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ACTS Clinical Trial Investigators, et al Ascorbic Acid, Corticosteroids and Thiamine in Sepsis 
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(ACTS) protocol and statistical analysis plan: a prospective, multicentre, double-blind, randomised, 
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placebo-controlled clinical trial BMJ Open 2019;9:e034406. All analyses were performed as 
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described in the published statistical analysis plan unless otherwise noted in the manuscript. 
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Supplement 1 additionally contains the original clinical trial protocol in addition to a summary of 
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changes made over time.  
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PROTOCOL V2.4 
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Ascorbic Acid, Hydrocortisone, and Thiamine in Sepsis and Septic Shock 
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– A Randomized, Double-Blind, Placebo-Controlled Trial 
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Acronym: Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) Trial 
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CLINICAL TRIAL PROTOCOL 
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             Version 2.4 
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December 13, 2018 
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            IND: 136882 
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Clinical Trials.Gov Identifier: NCT03389555 
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Principal investigator: 
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Michael W. Donnino, MD 
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Director of Center for Resuscitation Science 
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Associate Professor of Medicine, Harvard Medical School 
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Attending Physician in Emergency and Critical Care Medicine, BIDMC 
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Beth Israel Deaconess Medical Center 
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West Clinical Campus 2nd Floor 
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One Deaconess Road, Boston MA 02215 
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Phone: 617-754-2295 
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Fax: 617-754-2350 
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Email: mdonnino@bidmc.harvard.edu 
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Funded By: 
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Open Philanthropy Project (https://www.openphilanthropy.org/) 
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SYNOPSIS .........................................................................................................................................................6 
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TRIAL OVERVIEW ............................................................................................................................................7 
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STEERING COMMITTEE ................................................................................................................................8 
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TRIAL SITES ......................................................................................................................................................9 
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1. BACKGROUND AND SIGNIFICANCE ................................................................................................... 10 
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1.1 Scope of the Problem .......................................................................................................................... 10 
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1.2 Existing Interventions .......................................................................................................................... 10 
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1.3 The combination of vitamin C, hydrocortisone, and vitamin B1 may improve outcomes ......... 10 
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1.4 Physiologic Rationale .......................................................................................................................... 10 
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2. TRIAL DESIGN ........................................................................................................................................... 11 
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2.1 Overview ................................................................................................................................................ 11 
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2.2 Allocation ............................................................................................................................................... 11 
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2.3 Intervention ........................................................................................................................................... 11 
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2.3.1 Vitamin C, Hydrocortisone, and Vitamin B1 ............................................................................. 11 
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2.3.2 Placebo........................................................................................................................................... 11 
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2.4 Blinding .................................................................................................................................................. 11 
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2.5 
Regulatory Issues ........................................................................................................................... 11 
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3.  SETTING AND PARTICIPANT POPULATION .................................................................................... 12 
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3.1 Setting .................................................................................................................................................... 12 
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3.2 Inclusion criteria ................................................................................................................................... 12 
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3.3 Exclusion criteria .................................................................................................................................. 12 
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3.4 Pregnancy ............................................................................................................................................. 12 
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4. TRIAL PROCEDURES .............................................................................................................................. 13 
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4.1 Participant Identification ...................................................................................................................... 13 
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4.2 Consent procedures ............................................................................................................................ 13 
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4.3 Randomization ...................................................................................................................................... 13 
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4.4 Drug preparation and administration ................................................................................................. 13 
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4.4.1 Contingencies and Participant Withdrawal ............................................................................... 14 
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4.5 Specimen collection procedures ........................................................................................................ 14 
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4.5.1 Timing and volume of blood draw .............................................................................................. 14 
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4.5.2 Specimen samples ....................................................................................................................... 14 
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4.5.3 Biomarker tube initial processing and shipping ........................................................................ 15 
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4.6 Study flow diagram .............................................................................................................................. 15 
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4.7 General Sepsis Management ............................................................................................................. 15 
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4.8 Glucometer use during the study period .......................................................................................... 15 
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5. OUTCOMES ............................................................................................................................................... 16 
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5.1 Definitions .............................................................................................................................................. 16 
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5.1.1 Primary Outcome .......................................................................................................................... 16 
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5.1.2 Key Secondary Outcomes ........................................................................................................... 16 
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5.2 Rationale for Outcomes ...................................................................................................................... 17 
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5.3 Additional Secondary Outcomes ....................................................................................................... 17 
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5.3.1 Additional secondary outcomes .................................................................................................. 17 
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5.3.2 90-day follow-up for Quality of Life assessment ...................................................................... 17 
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5.4 Safety ..................................................................................................................................................... 18 
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5.4.1 Definitions ...................................................................................................................................... 18 
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5.4.2 Specific adverse event data collection ...................................................................................... 18 
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5.4.3 Adverse Event Reporting ............................................................................................................. 18 
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5.4.5 Safety Monitoring Labs ................................................................................................................ 19 
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6. SAMPLE SIZE CALCULATION AND STATISTICAL ANALYSIS PLAN ........................................... 19 
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6.1 Sample size calculation ....................................................................................................................... 19 
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6.2 Statistical analysis plan ....................................................................................................................... 20 
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6.2.1 General considerations ................................................................................................................ 20 
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6.2.2 SOFA score and renal failure...................................................................................................... 20 
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6.2.3 30-day mortality ............................................................................................................................. 20 
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6.2.5 Subgroup analyses ....................................................................................................................... 21 
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6.2.6 Statistical stopping criteria ........................................................................................................... 21 
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7. DATA COLLECTION AND MANAGEMENT .......................................................................................... 21 
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7.1 Data collection process ....................................................................................................................... 21 
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7.2 Variables ................................................................................................................................................ 21 
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7.3 Data quality and validity ...................................................................................................................... 21 
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7.4 Data storage and security ................................................................................................................... 21 
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8. ETHICAL CONSIDERATIONS ................................................................................................................. 22 
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8.1 Risks and Benefits ............................................................................................................................... 22 
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8.1.1 Potential benefits .......................................................................................................................... 22 
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8.1.2 Potential harms ............................................................................................................................. 22 
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9. MONITORING ............................................................................................................................................. 23 
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9.1 Institutional Review Board (IRB) ........................................................................................................ 23 
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9.2 Data Safety and Monitoring Board (DSMB) ..................................................................................... 23 
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10 CLINICAL MONITORING PLAN ............................................................................................................. 24 
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11. TIMELINE AND ENROLLMENT ............................................................................................................ 25 
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11.1 Timeline ............................................................................................................................................... 25 
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11.2 Screening & Enrollment .................................................................................................................... 25 
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12. FUNDING .................................................................................................................................................. 26 
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13. PUBLICATION .......................................................................................................................................... 26 
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14. DATA SHARING ...................................................................................................................................... 26 
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15. TASKS AND RESPONSIBILITIES ........................................................................................................ 26 
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References ...................................................................................................................................................... 27 
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Appendices ...................................................................................................................................................... 32 
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Appendix 1: Abbreviations ......................................................................................................................... 32 
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Appendix 2: CAM-ICU Form ..................................................................................................................... 33 
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SYNOPSIS 
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The “Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis (ACTS)” trial is a multi-center, double-
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blind, randomized clinical trial that aims to determine the impact of Vitamin C, Hydrocortisone, and 
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Vitamin B1 vs. Placebo on organ injury and mortality on participants with sepsis and septic shock. 
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The trial will be conducted in accordance with all applicable national and international laws, 
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regulations, and guidelines The trial and this protocol is developed in accordance with the 
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International Conference on Harmonization (ICH) guidelines1-3 and the Standard Protocol Items: 
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Recommendations for Interventional Trials (SPIRIT) statement4,5. The principal investigator wrote 
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the protocol with input from the steering committee. Any substantial changes or amendments to the 
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protocol will be clearly documented and communicated to all relevant parties.  
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TRIAL OVERVIEW 
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Title 
Vitamin C, Hydrocortisone, and Vitamin B1 in Sepsis and 
Septic Shock – A Randomized, Double-Blind, Placebo-
Controlled Trial (The ACTS Trial) 
Clinical Trials Number 
NCT03389555 
Sources of monetary or 
material support 
Open Philanthropy Project 
(https://www.openphilanthropy.org/)  
Study Sites 
12-sites in the United States 
Condition studied 
Sepsis and septic shock 
Interventions 
Vitamin C (1.5g every 6 hours x 4-days), hydrocortisone 
(50mg every 6 hours x 4-days), and Vitamin B1 (100mg 
every 6 hours x 4-days) 
Comparator  
Placebo  
Inclusion criteria 
 Adult participant (age ≥ 18 years) 
 Suspected (cultures drawn and antibiotic given) or 
confirmed (via culture results) infection 
 Receiving vasopressor (norepinephrine, 
phenylephrine, epinephrine, dopamine, vasopressin, or 
angiotensin II)  
Exclusion criteria 
 Member of a protected population (pregnant, prisoner) 
 Known history of kidney stones within the past 1 year 
 End stage renal disease (ESRD) requiring dialysis 
 Known history of G6PD deficiency 
 Known history of Hemochromatosis 
 Comfort Measures Only status 
 Anticipated death within 24-hours despite maximal 
therapy (as determined by the enrolling physician) 
 Receiving supplemental vitamin B1 in a dose greater 
than that contained in a multivitamin (<2mg) 
 Clinical indication for steroids (e.g. chronic use) as 
determined by the clinical team providing this drug 
 Clinical indication for ascorbic acid supplementation in 
any form  
 Clinical indication for vitamin B1 as determined by the 
clinical team providing this drug 
 Known allergy to vitamin C, hydrocortisone, or vitamin 
B1 
Study type 
Interventional 
Allocation: Randomized (1:1) 
Intervention model: Parallel group 
Masking: Double-blind 
Target sample size 
200 Participants (100/arm) 
Primary outcome 
Change in the Sequential Organ Failure Assessment 
(SOFA) score between enrollment and 72-hours 
Key secondary outcomes 
Incidence of renal failure during index ICU stay 
30-day mortality 


 
STEERING COMMITTEE 
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Michael Donnino, M.D.  
Associate Professor of Medicine 
Director, Center for Resuscitation Science  
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Paul E. Marik, M.D.* 
Professor of Medicine 
Chief, Division of Pulmonary and Critical 
Care Medicine 
Eastern Virginia Medical School 
Ari Moskowitz, M.D. 
Attending, Pulmonary and Critical Care Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Katherine Berg, M.D. 
Assistant Professor of Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Lars W. Andersen, M.D., MPH, Ph.D 
Associate Professor of Medicine 
Research Center for Emergency Medicine 
Department of Clinical Medicine 
Aarhus University and Aarhus University Hospital 
Anne Grossestreuer, Ph.D. 
Instructor in Emergency Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Michael N. Cocchi, MD 
Assistant Professor of Emergency Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Joseph Miller, MD 
Attending, Emergency Medicine 
Department of Emergency Medicine 
Henry Ford Hospital 
Conflicts of interest 
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The members of the steering committee have no financial conflicts of interest related to the current 
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trial.  
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*Stepped down from Steering Committee prior to publication. Was not a site investigator.  
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TRIAL SITES 
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Coordinating Center 
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Beth Israel Deaconess Medical Center 
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330 Brookline Avenue 
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Boston, MA 02215 
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Site Investigator: Michael W. Donnino, MD 
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Enrolling Sites* 
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Hospital Name 
Location 
Site Principal Investigator 
Henry Ford Hospital 
Detroit, MI 
Junior Uduman, MD 
DMC-Detroit Receiving Hospital 
Detroit, MI 
Rob Sherwin, MD 
DMC-Sinai-Grace Hospital 
Detroit, MI 
Rob Sherwin, MD 
Harper Hospital 
Detroit, MI 
Rob Sherwin, MD 
UT Health, The University of Texas 
Health Science Center 
Houston, TX 
Pratik Doshi, MD 
Mayo Clinic 
Phoenix, AZ 
Ayan Sen, MD 
Beth Israel Deaconess Medical 
Center 
Boston, MA 
Ari Moskowitz, MD 
Beaumont Hospital 
Royal Oak, MI 
Ron Otero, MD 
Brigham and Women’s Hospital 
Boston, MA 
Peter Hou, MD 
Long Island Jewish Hospital Center 
- Queens 
New York, NY 
Maksim Korotun, MD; Jonathan 
Gong, MD 
Long Island Jewish Hospital Center 
– Hyde Park 
New York, NY 
Ayelet Hilewitz, MD; Jonathan 
Gong, MD 
Mount Auburn Hospital 
Cambridge, MA 
Jessica McCannon, MD 
University of Pittsburgh 
Pittsburgh, PA 
David Huang, MD 
South Shore Hospital 
Weymouth, MA 
Mark Hershey, MD 
*Depending on study progress, sites may be added or removed in the future. 
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1. BACKGROUND AND SIGNIFICANCE 
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1.1 Scope of the Problem  
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The worldwide incidence of sepsis has been estimated at more than 23 million cases6 and sepsis 
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contributes to more than a third of all hospital deaths in the United States.7,8 Mortality for those in 
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septic shock with elevated lactate is more than 40%.9 In addition to high short-term mortality, sepsis 
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is associated with significant post-discharge morbidity and mortality.10-15 The economic burden for 
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participants suffering from sepsis is staggering with an estimated yearly financial burden of $17 
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billion.16 Treatments are generally limited to antibiotics and intravenous fluids while providing 
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support to maintain organ function.17,18  
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1.2 Existing Interventions 
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To date, numerous interventions have been tested for participants with sepsis and septic shock with 
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limited, if any, success.19-22 Recently, three large studies found no benefit from early goal directed 
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therapy over usual care in emergency department participants with sepsis.23-25 Other recent studies 
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focusing on hemodynamics, fluid therapy, and transfusions have also failed to show a significant 
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benefit in this participant population.26-28 Previous studies focusing on immunomodulary therapies or 
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drotrecogin alfa have likewise shown disappointing results.29-35  
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1.3 The combination of vitamin C, hydrocortisone, and vitamin B1 may improve outcomes  
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In a before-and-after study exploring the effects of the combination of vitamin C, hydrocortisone, and 
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vitamin B1 in a cohort of participants with sepsis and septic shock, Marik et. al. found a remarkable 
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improvement in time to shock reversal (18.3 ± 9.8 hours vs. 54.9 ± 28.4 hours), organ injury (ΔSOFA 
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4.8 ± 2.4 vs. 0.9 ± 2.7), and mortality (8.5% vs. 40.4%) following implementation of the drug ‘cocktail’ 
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as compared to before implementation even after adjusting for potential confounders.36 This study 
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joins other promising trials of individual elements of this drug combination. In a trial of vitamin B1 in 
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septic shock, there was a substantial reduction in mortality and organ injury (particularly kidney 
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injury) in those with vitamin B1 deficiency and septic shock who were given vitamin B1 as compared 
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to placebo.37,38 In addition, several studies of vitamin C alone have shown promise in critically ill 
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populations39-42 and a recent meta-analysis of corticosteroids in sepsis suggests potential benefit.43 
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1.4 Physiologic Rationale 
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The combination of vitamin C, hydrocortisone, and vitamin B1 is hypothesized to improve outcomes 
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in sepsis through a number of mechanisms.36 Vitamin C is an important contributor to endothelial 
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integrity and severe deficiency states (e.g. scurvy) can result in endothelial breakdown with resultant 
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vascular leak and edema.44,45  In addition, vitamin C is a potent anti-oxidant and is integral to 
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endogenous vasopressor synthesis.36 Hydrocortisone, a potential adjunctive therapy in septic 
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shock46,47, may act synergistically with vitamin C.48,49 Vitamin B1, a key cofactor of pyruvate 
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dehydrogenase, is a critical component of metabolic dysfunction without which a shift towards 
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anaerobic energy production occurs.50 Vitamin B1 is also a necessary component of the pentose 
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phosphate pathway, which plays a role in reducing oxidative stress.51,52 While the physiologic effects 
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of these drugs given in combination is not entirely known, we hypothesize that there will be 
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synergistic effects with respect the metabolic resuscitation of sepsis.  
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2. TRIAL DESIGN 
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2.1 Overview 
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This will be an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, 
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double-blind, superiority trial of vitamin C, hydrocortisone, and vitamin B1 vs. placebo in participants 
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with sepsis and septic shock. A total of 200 adult participants will be enrolled. The primary outcome 
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will be the change in SOFA score between enrollment and 72-hours. Key secondary outcomes 
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include the incidence of renal failure during the index ICU stay and survival at 30 days. 
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2.2 Allocation 
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Participants will be randomized in a 1:1 ratio to either the combination of vitamin C, hydrocortisone, 
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and vitamin B1 or placebo in blocks with random sizes of 2 or 4. The randomization will be stratified 
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according to site.53 An independent statistician will create the randomization list using a random 
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number generator. The complete list will only be shared with an independent pharmacy consultant, 
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who will not be involved in clinical care. The pharmacy consultant and the independent statistician 
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will both store the randomization list. The research pharmacy at each enrolling site will receive a 
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site-specific randomization list.   
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2.3 Intervention 
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2.3.1 Vitamin C, Hydrocortisone, and Vitamin B1 
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The study drugs will consist of vitamin C (1.5g every 6 hours x 4-days), hydrocortisone (50mg every 6 
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hours x 4-days), and vitamin B1 (100mg every 6 hours x 4-days). 
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2.3.2 Placebo  
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The placebo will consist of matching volumes of normal saline (0.9% NaCl). See below section 4.4 
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for specifics of drug and placebo preparation.  
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2.4 Blinding  
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The trial will be double-blind; participants, investigators, and the clinical team will be blinded to the 
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allocation. Only the pharmacy providing the study drug will be aware of the allocation. The 
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pharmacy will not be involved with clinical care or outcome evaluation.  
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As vitamin C possess a yellow tinge, the bags containing the vitamin C/placebo will be covered with 
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light-protective bags. In testing, after dilution there is not distinguishing characteristics of the vitamin 
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C vs. placebo in the IV tubing. Vitamin C, hydrocortisone, and vitamin B1 are not known to have 
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distinctive rapid effects which could lead to unblinding.  
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The decision to unblind will be at the complete discretion of the treating physician and clinical team. 
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If a clinical team wishes to unblind a participant (e.g. if anaphylaxis occurs), they will contact the 
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research pharmacy who will reveal the study group to the clinical team (but the research team will 
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remain blinded). However, we do not expect many scenarios where emergency unblinding will be 
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necessary. In case unblinding occurs, the reason(s) will be clearly documented in the case report 
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form. The patient will no longer receive study medications, but will be followed for outcomes.  
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2.5 Regulatory Issues 
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An Investigational New Drug (IND) application was submitted to and approved by the Food and 
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Drug Administration (FDA) for the study of vitamin C, hydrocortisone, and vitamin B1 in sepsis and 
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septic shock (IND # 136882). 
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The trial has been registered on ClinicalTrials.gov: NCT03389555 
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3.  SETTING AND PARTICIPANT POPULATION 
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3.1 Setting 
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The trial will be conducted at approximately 13 hospitals in the United States. Additional sites might 
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be recruited if needed.  
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3.2 Inclusion criteria 
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Inclusion criteria:  
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1) Adult participant (age ≥ 18 years) 
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2) Suspected (cultures drawn and antibiotic given) or confirmed (via culture results) infection 
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3) Receiving (continuous infusion) vasopressor (norepinephrine, phenylephrine, epinephrine, 
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dopamine, angiotensin II, or vasopressin) 
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a. Hypotension related primarily to sepsis as opposed to another cause of hypotension 
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(e.g. bleed, cardiogenic shock) 
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3.3 Exclusion criteria  
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Exclusion criteria: 
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1) Member of a protected population (pregnant, prisoner) 
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2) Known history of kidney stones within the past 1 year (not including incidentally noted stones 
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noted on imaging studies) 
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3) End stage renal disease requiring dialysis (hemodialysis or peritoneal dialysis) 
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4) Known history of G6PD deficiency 
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5) Known history of Hemochromatosis 
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6) Comfort Measures Only status 
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7) Anticipated death within 24-hours despite maximal therapy (as determined by the enrolling 
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physician)  
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8) Receiving supplemental vitamin B1 in a dose greater than that contained in a multivitamin 
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(<2mg) 
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9) Clinical indication for steroids (e.g. chronic use) as determined by the clinical team providing 
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this drug 
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10) Clinical indication for ascorbic acid supplementation in any form  
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11) Clinical indication for vitamin B1 as determined by the clinical team providing this drug 
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12) Known allergy to vitamin C, hydrocortisone, or vitamin B1 
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Justification of Inclusion and Exclusion Criteria: The inclusion criteria were chosen to isolate a septic 
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participant population with high risk of organ injury and death. The exclusion criteria were chosen to 
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minimize the risk of potential harm and to ensure that participants enrolled do not already have 
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chronic end-stage renal failure with a high likelihood of early need for renal replacement therapy. By 
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evaluating this high-risk population (i.e., most likely to die), we will target those most likely to benefit 
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and therefore increase the probability of showing efficacy.19  
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3.4 Pregnancy 
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Hydrocortisone is considered pregnancy class C on the basis of animal studies showing an 
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association between prenatal parenteral hydrocortisone use and risk of cleft-palate. In addition, 
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there are concerns about effects of hydrocortisone on fetal growth and the possibility of neonatal 
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adrenal insufficiency. The effects of high-dose vitamin C and thiamine in pregnancy are not entirely 
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known. As such, participants who are pregnant will be excluded from the study. Prior to enrollment, 
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all participants of potentially child-bearing potential (women aged <45 years54) will be required to 
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have a negative serum or urine HCG test (generally performed as standard-of-care).  
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We will additionally inform all women of child-bearing potential who are randomized in this study 
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that we recommend they remain abstinent or use two forms of birth control during the study period 
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and for a period of 48-hours after the last dose of study drug.  
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4. TRIAL PROCEDURES 
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4.1 Participant Identification  
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Screening will be performed in the emergency department and intensive care units (ICUs) with the 
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assistance of electronic screening mechanisms . Detailed screening logs, with reason(s) for 
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exclusion will be kept at each site and reported in the final publication.  
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We anticipate that all patients, as part of standard-of-care for the septic patient, will have a urine or 
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serum HCG test performed (if a female of child-bearing age). If this test is not sent as part of 
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standard-of-care, it should be sent prior to consent.   
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4.2 Consent procedures 
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Informed, written consent will be obtained for all participants prior to enrollment.  
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After it is determined that they meet all inclusion criteria and no exclusion criteria, the participant (or 
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legally authorized representative [LAR] if the participant is not able to provide consent) will be 
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approached for written informed consent by a physician co-investigator from the team. The 
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investigator will provide the participant/representative information regarding the background and 
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significance of the study, eligibility criteria, and a description of the protocol. To ensure we are 
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correctly identifying the potential participant’s LAR, we communicate with members of the clinical 
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team. The consent process may need to be modified based on site-specific IRB recommendations.  
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The name of the study investigator obtaining consent will be clearly documented, and this person 
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will sign the informed consent document and provide the date and time of their signature. If a 
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physician is performing remote consent, then a copy of the consent form will be signed as soon as 
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he/she is physically present. Signed copies of the consent form will be given to the 
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participant/surrogate, and the original consent document will be stored in the secure study file. In 
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obtaining and documenting informed consent, each investigator will comply with the applicable 
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regulatory requirements and adhere to the ethical and Good Clinical Practice principles that have 
396 
their origin in the Declaration of Helsinki.  
397 
 
398 
4.3 Randomization 
399 
After consent is obtained, the research team will notify the local research pharmacy. The research 
400 
pharmacy will be in possession of the randomization list and will determine which arm (intervention 
401 
vs. placebo) the participant will be enrolled in.  
402 
 
403 
Patients should be randomized, consented, and enrolled in the study as soon as possible after 
404 
meeting inclusion criteria. Patients should not be consented if it has been >24hours since the 
405 
patient met inclusion criteria (i.e. start of vasopressors). At the time of randomization and study drug 
406 
administration, the patient should still be receiving a vasopressor. The patient should not be given 
407 
study drug if the vasopressor has been stopped (e.g. patient met inclusion criteria overnight but 
408 
could not be consented for logistical reasons and then improves to the point of no longer requiring a 
409 
vasopressor). In this scenario, the paitent will be entered into the dabase as consented but not 
410 
enrolled.  
411 
 
412 
4.4 Drug preparation and administration 
413 
The vitamin C and vitamin B1 will be mixed together in 100ml of normal saline and administered 
414 
intravenously over 45-60 minutes. The hydrocortisone will be given intravenously as a push-dose in 
415 
1ml of saline over 1-2 minutes. The placebo will be given using techniques and volumes matching 
416 
those of the study medications. 
417 


 
 
418 
All study medications will be continued for 4-days or until the participant expires or leaves the 
419 
intensive care unit.  
420 
 
421 
4.4.1 Contingencies and Participant Withdrawal  
422 
 In the unlikely event that a participant is discharged alive from the hospital prior to 4 days after 
423 
enrollment, all study medications will be stopped.The participant will remain in the study and will 
424 
be followed for outcomes. 
425 
 Hydrocortisone is occasionally used for refractory septic shock. If the clinical team opts to provide a 
426 
participant hydrocortisone, the hydrocortisone will be given open-label but the vitamin C/B1 will 
427 
remain randomized and blinded. In this case, the research team will ensure that study 
428 
hydrocortisone/placebo is replaced by open-label hydrocortisone. The participant will remain in 
429 
the study and will be followed for outcomes. 
430 
 If the clinical team decides to give the participant vitamin B1 for clinical purposes, the study drug 
431 
will be continued (including thiamine) as long as the total maximum dose of vitamin B1 is 
432 
≤1,500mg/day. 1,500mg day is a standard dose for Wernicke’s encephalopathy at many 
433 
institutions and has not been associated with any increased harm.  
434 
 If the clinical team decides to give the participant vitamin C for clinical purposes, further 
435 
administration of study meds will be stopped. The participant will remain in the study and will be 
436 
followed for outcomes.  
437 
 If a participant withdraws from the study, further administration of study meds will be stopped. 
438 
Data collected prior to withdrawal will be maintained but additional data will not be collected.   
439 
 
440 
4.5 Specimen collection procedures 
441 
4.5.1 Timing and volume of blood draw 
442 
All participants will have a blood samples collected at four time-points and urine samples at two 
443 
time-points (if not already available as part of routine clinical care). Blood will be obtained by 
444 
venipuncture, or from an existing venous or arterial catheter. Urine will be collected via clean catch 
445 
urine or via catheter.  
446 
 
447 
Specimen Collection Time Points 
448 
1. T1=0 hrs (just before study drug administration) 
449 
2. T2=24 hrs (+/- 2 hrs) 
450 
3. T3=72 hrs (+/- 2 hrs) 
451 
4. T4=120hrs (+/- 12hrs) 
452 
 
453 
4.5.2 Specimen samples 
454 
At the T1, T2, T3, and T4 time points, blood will be sent for complete blood count (including 
455 
hemoglobin, white blood cell count, platelet count), a serum chemistry (including sodium, 
456 
potassium, chloride, bicarbonate, blood urea nitrogen, creatining, glucose, aspartate transaminase, 
457 
alanine transaminase, and total bilirubin), and a venous blood gas to measure lactate. These tests 
458 
will be performed by the clinical laboratory at each site. As many of these laboratory tests are 
459 
commonly obtained for clinical purposes, these tests do not need to be repeated if a result is 
460 
available from the clinical care of the participant within 2 hours of the time point (or within 12 hours 
461 
of the T4 time-point).  
462 
 
463 
In addition to traditional clinical markers, blood will be obtained for future biomarker analysis 
464 
(including inflammatory biomarkers, markers of endothelial function, and markers of mitochondrial 
465 
function), and measurement of vitamin C, vitamin B1, and cortisol levels. The total volume of blood 
466 
that may be drawn for a participant at each time point will not exceed 60mls. Levels of vitamin C, 
467 
vitamin B1, and cortisol will be measured at time T1 and time T3 only. 20ml of urine will be collected 
468 
for future biomarker analysis at T1, T2, and T3. 
469 


 
 
470 
If performed as part of standard-of-care, results of urinalysis and urine sediment testing will be 
471 
collected prior to enrollment.  
472 
 
473 
4.5.3 Biomarker tube initial processing and shipping 
474 
Please see accompanying blood collection standard operating procedure for full details. In brief, 
475 
15ml of blood will be drawn into EDTA tubes and 10ml of blood will be drawn into a corvac tube. 
476 
From one of the EDTA tubes, 3ml of whole blood will be initially drawn and separated into 3x 1ml 
477 
aliquots. Plasma will then be isolated from the EDTA tube(s) and aliquoted into cryovials as follows: 
478 
4x 0.5ml aliquots and the remainder in 1ml aliquots. Serum will then be isolated from the corvac 
479 
tube, and separated into 1ml aliquots. Cryovials will be protected from light and frozen at -80°C until 
480 
processing. An additional 20ml of urine will also be collected, centrifuged, and separated into 1ml 
481 
aliquots then frozen at -80°C until processing. 
482 
 
483 
Sites will be expected to ship frozen samples to the coordinating center after every 5 enrollments. 
484 
The coordinating center will assist with all shipping procedures.  
485 
 
486 
4.6 Study flow diagram 
487 
 
488 
 
489 
 
490 
4.7 General Sepsis Management  
491 
Investigators should follow local sepsis management guidelines. No specific sepsis bundle is 
492 
required by this study, however the early administration of antibiotics, maintenance of a mean 
493 
arterial pressure ≥65mmHg with a combination of volume resuscitation and vasopressors, and early 
494 
source control are recommended—as detailed in the Suriving Sepsis Guidelines.55 Elements of 
495 
sepsis care should be reported on the online case report form (CRF). 
496 
 
497 
4.8 Glucometer use during the study period 
498 
High dose vitamin C has been shown to falsely elevate glucose level readings when measured with 
499 
certain point-of-care glucometers employing glucosedehydrogenase-pyrroloquinoline quinone 
500 
amperometric methods56. Some commonly used glucometer brands using this approach include 
501 
Accu-Chek (Roche Diagnostic) and Optium (Abbott Diabetes Care) (but not StatStrip; Nova 
502 
Biomedical). While the effects of high-dose vitamin C on glucometer readings have been seen 
503 
primarily at higher doses of vitamin C than are intended for use in this trial,56 we recommend that 
504 
sites explore what glocumeters are in use in local ICUs. If locally used glucometers may be 
505 


 
impacted by high serum concentrations of vitamin C (as determined by the manufacturer), we 
506 
recommend that clinical teams caring for enrolled participants be alerted to the possibility of falsely 
507 
elevated blood-glucose levels when measured by glucometer. If there is a clinical concern about a  
508 
glucose reading obtained via glucometer, a serum glucose should be obtained which will not be 
509 
impacted by vitamin C. In the event of an emergency related to suspected hypoglycemia, glucose 
510 
should be immediately given while a serum glucose level is pending.  
511 
 
512 
5. OUTCOMES 
513 
5.1 Definitions 
514 
5.1.1 Primary Outcome 
515 
The primary outcome will be the absolute change in the Sequential Organ Failure Assessment 
516 
(SOFA]) score from enrollment (time=0) to 72 hours after drug administration. The SOFA score will 
517 
be defined using a modification in which the SaO2/FiO2 ratio is substituted for the PaO2/FiO2 ratio 
518 
as has been previously described.57,58 This modified score will be used so that participants without 
519 
an existing arterial catheter can be spared arterial puncture.  
520 
 
521 
Points 
SaO2*/FiO2§ 
Blood Pressure 
GCS‖ 
Bilirubin 
(mg/dL) 
Creatinine 
(mg/dL) 
Platelets 
(x103µL) 
1 
<400 
< 70 mm/Hg 
13–
14 
1.2–1.9 
1.2 – 1.9 
<150 
2 
<326 
dopamine ≤ 5 µg/kg/min or 
dobutamine  
(any dose) 
10–
12 
2–5.9 
2.0 – 3.4 
<100 
3 
<236 (and receiving 
invasive or non-invasive 
mechanical ventilation) 
dopamine > 5µg/kg/min, 
epinephrine/norepinephrine  
≤ 0.1 µg/kg/min 
6–9 
6–11.9 
3.5 – 4.9 
Or 
UOP†<500ml/day 
<50 
4 
<151(and receiving 
invasive or non-invasive 
mechanical ventilation) 
dopamine > 15, 
epinephrine/norepinephrine 
> 0.1 µg/kg/min  
<6 
>12 
> 5.0 
UOP†<200ml/day 
Or receiving 
renal 
replacement 
therapy 
<20 
*SaO2=Oxygen saturation (%); § = Fraction of inspired oxygen (%); ‖ = Glasgow Coma Scale; † = Urine Output 
522 
Fio2 will be determined by using either the set FiO2 (for patients receiving invasive or non-invasive 
523 
mechanical ventilation) or by adding 3% FiO2 for each liter/minute of supplemental oxygen added 
524 
up to 100% FiO2 (for patients not receiving mechanical ventilation). Patients with an SaO2/FiO2 
525 
ratio <236 who are not receiving invasive or non-invasive mechanical ventilation, will be assigned a 
526 
score of 2.  
527 
 
528 
5.1.2 Key Secondary Outcomes 
529 
Incidence of Acute Renal Failure – Renal failure will be defined as the development of Kidney 
530 
Disease Improving Global Outcomes [KDIGO] Stage 3 acute kidney injury during the index ICU stay 
531 
after study enrollment.58 
532 
 
533 
KDIGO Stage 
Serum creatinine criteria 
Urine output criteria 
1 
Increase in serum creatinine of 
more than or equal to 0.3 mg/dl (≥ 
26.4 μmol/l) or increase to more 
than or equal to 150% to 200% (1.5- 
to 2-fold) from baseline 
Less than 0.5 ml/kg per hour for 
more than 6 hours 
2 
Increase in serum creatinine to 
more than 200% to 300% (> 2- to 3-
fold) from baseline 
Less than 0.5 ml/kg per hour for 
more than 12 hours 
3 
Increase in serum creatinine to 
more than 300% (> 3-fold) from 
baseline (or serum creatinine of 
Less than 0.3 ml/kg per hour for 
24 hours or anuria for 12 hours 
OR 


 
more than or equal to 4.0 mg/dl [≥ 
354 μmol/l] with an acute 
increase of at least 0.5 mg/dl [44 
μmol/l])  
New renal replacement therapy 
(RRT) 
 
534 
30-Day Mortality – Mortality at 30-days. This will be assessed by review of the medical records if the 
535 
participant remains in the hospital or if the participant expired while in the hospital. If the participant 
536 
was discharged, 30-day mortality will be assessed by contacting the participant by phone or by 
537 
searching the National Center for Health Statistics (NCHS) National Death Index (NDI) consistent 
538 
with a recent multicenter phase III trial in sepsis.23 Phone calls will be made by the research team at 
539 
each site.  
540 
 
541 
5.2 Rationale for Outcomes  
542 
Change in SOFA score: Organ failure is highly associated with mortality60 and improvement in 
543 
organ function is a key goal for critical care physicians. In the study by Marik et al.36, participants 
544 
who received the 3-drug regimen had substantial improvements in the trajectory of organ failure 
545 
over the first 72-hours of their ICU stay. If the combination of vitamin C, hydrocortisone, and vitamin 
546 
B1 can improve organ function in the first 72-hours following ICU admission, we believe that 
547 
clinicians will likely quickly adopt this safe and inexpensive therapy. Importantly, this outcome can 
548 
be measured early in the hospital stay and is therefore less likely to be affected by other potential 
549 
elements of hospital care that can affect more distal outcomes (e.g., mortality).  
550 
 
551 
Kidney Injury: Renal failure has been estimated to occur in 23% of participants with sepsis and 
552 
over 50% of participants with septic shock.61 In studies of participants with septic shock, there is a 
553 
step-wise increase in mortality with worsening acute kidney injury (AKI).62 In addition, many 
554 
participants who experience renal injury during septic shock do not recover renal function prior to 
555 
hospital discharge and may require long term dialysis. As both data from the study by Marik et. al.36 
556 
and a separate study of vitamin B1 in septic shock38 have shown substantial improvements in renal 
557 
outcomes, kidney failure is a natural secondary outcome and one that could change practice 
558 
independently from other factors – in other words, many clinicians would likely provide this therapy if 
559 
they knew that kidney function could be protected, since this organ is vital to long-term health. 
560 
 
561 
Mortality: Finally, we will measure 30-day mortality. We anticipate that the combination of vitamin 
562 
C, hydrocortisone, and vitamin B1 will reduce mortality in this high-risk population.  
563 
 
564 
5.3 Additional Secondary Outcomes 
565 
5.3.1 Additional secondary outcomes 
566 
Additional secondary outcomes will include length of ICU stay, length of hospital stay, ventilator-free 
567 
days over the first 7-days after enrollment, shock-free days over the first 7-days after enrollment, 
568 
and the incidence of delirium on day #3 of the ICU stay (as assessed using the Confusion 
569 
Assessment Method [CAM-ICU] system).63 Sites at which the CAM-ICU is performed daily as part of 
570 
standard-of-care should assess whether delirium occurs on any day during the initial ICU stay. See 
571 
Appendix #2.  
572 
 
573 
5.3.2 90-day follow-up for Quality of Life assessment 
574 
Sites may choose to participate in a long-term outcomes substudy exploring the effects of ascorbic 
575 
acid, hydrocortisone, and thiamine vs. placebo on quality of life following sepsis. If a site chooses to 
576 
participate, a trained research assistant/investigator at the site (who is blinded to treatment arm) will 
577 
contact all participants who were alive at 30-days, and perform the SF-36 at day 90 following 
578 
enrollment. The SF-36 is a 36-Item Short-Form Health Survey (SF-36), a validated survey of 
579 
general quality of life in adults, can be administered in person or over the telephone by research 
580 


 
personnel. It measures eight different dimensions: physical functioning, bodily pain, role limitations 
581 
due to physical health problems, role limitations due to personal or emotional problems, emotional 
582 
well-being, social functioning, energy/fatigue, and general health perceptions, as well as one 
583 
question asking about perceived changes in health. The telephone version of the 36-Item Short-
584 
Form Health Survey has been validated64,65 and used in sepsis.66-69  
585 
 
586 
5.4 Safety 
587 
5.4.1 Definitions  
588 
The following definitions will be used70:  
589 
 
590 
Adverse event: any untoward medical occurrence in a participant to whom a medicinal product is 
591 
administered and which does not necessarily have a causal relationship with this treatment 
592 
 
593 
Serious adverse event: any untoward medical occurrence that at any dose requires inparticipant 
594 
hospitalization or prolongation of existing hospitalization, results in persistent or significant disability 
595 
or incapacity, results in a congenital anomaly or birth defect, is life-threatening, or results in death 
596 
 
597 
Unexpected serious adverse event: a serious adverse reaction, the nature, severity or outcome of 
598 
which is not consistent with the reference safety information 
599 
 
600 
 
601 
5.4.2 Specific adverse event data collection 
602 
To assess specific amd potentially serious adverse events that may be related to the combination of 
603 
the study medications, we will collect data on the following:  
604 
 
605 
Serious Adverse Event 
Definition 
Hyperglycemia 
Serum glucose >300mg/dl in the first 120-hours after 
enrollment 
Hypernatremia 
Serum sodium (> 150 mmol/L) occurring in the first 120-
hours after enrollment 
New Infection 
As determined by the site principal investigator at each 
site. Should be a new organism or site of infection and 
believed to be unrelated to the initial presenting 
infectious source. Many will have the initiation of new 
antibiotics or a change in antibiotics. 
Catheter-site 
Lung 
Gastrointestinal 
Urinary tract 
Other 
Serious allergic reaction 
Anaphylaxis or other allergic reaction requiring systemic 
corticosteroids. Allergic reaction should be related (or 
suspected to be related) to the study medicaiton  
Renal calculus 
Development of a renal calculus between enrollment 
and 30-day follow-up (based on question asked during 
follow-up phone call). 
 
606 
5.4.3 Adverse Event Reporting 
607 
All unexpected serious adverse events thought to be related to the study drug, and any 
608 
unexpected fatal or life-threatening adverse events thought to be related to the study drug 
609 
will be recorded in the online CRF, reported directly to the coordinating center, and reported 
610 
to the appropriate IRB shortly following the event per local protocol. In addition, unexpected 
611 
serious adverse events related to the study drug will be undergo expedited reporting to the 
612 
DSMB within 7 days of the coordinating center becoming aware of the event. The DSMB will 
613 
additionally review all adverse events in aggregate after every 50 patients are enrolled. 
614 
 
615 
Adverse events will additionally be reported to the FDA as outlined in 21CFR312.32 and 
616 
summarized below: 
617 


 
a. All unexpected fatal or life-threatening adverse events thought to be related to the 
618 
study drug will be reported to the FDA within 7 calendar-days of when the ACTS 
619 
team is made aware of the event. 
620 
b. All unexpected serious adverse events thought to be related to the study drug will be 
621 
reported to the FDA within 15 calendar-days of when the ACTS team is made aware.  
622 
c. All serious unexpected adverse events, and any unexpected fatal or life-threatening 
623 
events thought to be related to the study drug, will be reported back to all site 
624 
investigators within 15 calendar-days of the event. 
625 
d. The ACTS team will periodically review all published information relating to the safety 
626 
of each element of the drug combination. Any concerning safety information obtained 
627 
from this review, or otherwise obtained (e.g. from unpublished scientific papers), will 
628 
be reported to the FDA within 15 calendar-days. 
629 
 
630 
5.4.5 Safety Monitoring Labs 
631 
As detailed above, safety monitoring labs will be obtained at 120-hours, after completion of the 
632 
study protocol.  
633 
 
634 
6. SAMPLE SIZE CALCULATION AND STATISTICAL ANALYSIS PLAN  
635 
6.1 Sample size calculation 
636 
The study has been powered to have at least 80% power for the primary outcome and all key 
637 
secondary outcomes as follows: 
638 
 
639 
SOFA Score: Based on preliminary data36, we conservatively anticipate a decrease in SOFA score 
640 
of 6 (standard deviation [SD]: 4) in the treatment group and 4 (SD: 2) in the placebo group. With 
641 
these estimates, enrollment of 200 participants (100/arm) at an alpha of 0.05 and using a t-test 
642 
with unequal variance, the trial will provide > 99% power to detect a statistical significant difference 
643 
between groups.  
644 
 
645 
Kidney Injury: Based on preliminary data from our study of vitamin B1 in septic shock,38 we 
646 
anticipate that 30% of participants in the treatment group and 55% in the placebo group will have 
647 
renal failure which will result in a 94% power for this outcome. This calculation and following 
648 
calculation were performed using the Fisher’s exact test. 
649 
  
650 
Mortality: Based on preliminary data36,37,71, we anticipate that the control group will have a mortality 
651 
of 40%. We estimate a treatment effect of 50% (risk ratio: 0.50) resulting in a mortality of 20% in the 
652 
treatment group. With these estimates, 182 participants will lead to 80% power. To further increase 
653 
the trial’s power and due to potential loss-to-follow-up, we will aim to enroll 200 participants. These 
654 
estimates are conservative compared to the Marik et al. study which found a treatment effect 
655 
corresponding to a risk ratio of 0.21 which persisted in adjusted analysis.36  
656 
 
657 
Sample Size Adjustment 
658 
 
659 
If after 100 patients are enrolled, the overall change in SOFA score is less than anticipated in the 
660 
above power analysis and/or the renal failure event rate or mortality rate is lower than predicted, the 
661 
enrollment target of 200 patients may be adjusted accordingly so as to improve power for the 
662 
primary outcome and all key secondary outcomes at the end of the trial period. Specifically, we will 
663 
aim to maintain ≥90% power to detect a 2-point difference in ΔSOFA score (using variance seen for 
664 
the full cohort) and ≥80% power to detect a 50% treatement effect on mortality. Whether to increase 
665 
the study sample size, and the degree of sample size increase, will be decided on by the blinded 
666 
Steering Committee who will not have access to data stratified by treatment group. The Steering 
667 


 
Committee will take into account logistical and financial considerations when updating the 
668 
enrollment target.  
669 
 
670 
6.2 Statistical analysis plan 
671 
6.2.1 General considerations 
672 
The statistical analyses and reporting will adhere to the CONSORT guidelines.72,73 All tests will be 
673 
two-sided, a p-value < 0.05 will be considered significant, and all confidence intervals will have 95% 
674 
coverage. All analyses will be conducted on a modified intention-to-treat basis only including 
675 
participants receiving at least the first dose of the study medications. In a double-blind trial, this 
676 
approach is unbiased while increasing precision.74 The two groups will be compared in relation to 
677 
baseline characteristics using descriptive statistics.  
678 
 
679 
The persons conducting the statistical analysis will be blinded to the randomized allocation. Groups 
680 
will be designated as “A” and “B” until all pre-specified analyses are performed and shared with all 
681 
authors and the Data Safety Monitoring Board. 
682 
 
683 
6.2.2 SOFA score and renal failure 
684 
The change in SOFA score will be calculated and compared between groups using the Wilcoxon 
685 
Rank Sum test (if the change is not normally distributed) or by a t-test if the change is approximately 
686 
normally distributed. Fisher’s exact tests will be used to compare the incidence of renal failure 
687 
during the index ICU stay. 
688 
  
689 
If a participant expires prior to the 72-hour time point, SOFA scores will be imputed based on a pre-
690 
defined plan as follows. If a participant expires before 24-hours has elapsed, a 20% increase from 
691 
baseline will be imputed. If a participant expires between 24-hours and 48-hours, a 15% increase 
692 
from the 24-hour time point will be imputed. If a participant dies between 48-hours and 72-hours, a 
693 
20% increase from the 24-hour time point will be imputed. Sensitivity analyses will be performed 
694 
using various other imputation techniques. Specifically, we will perform 1) a sensitivity analysis in 
695 
which the worst possible SOFA score (score of 24) is imputed for those participants who expire, 2) a 
696 
sentivity analysis in which the last SOFA score for participants who expire will be carried forward, 
697 
and 3) a sensitivity analysis in which only those patients who survive to 72-hours are included. 
698 
These sensitivity analyses were chosen to model ‘worst-possible’ and ‘best-possible’ scenarios. For 
699 
the secondary outcome of renal failure, participants who expire during their ICU stay will be 
700 
assessed to have developed renal failure if they demonstrated any degree of unresolved KDIGO 
701 
acute kidney injury prior to death. If there was no evidence of acute kidney injury prior to death or if 
702 
kidney injury had fully resolved, these participants will be assessed as not having developed renal 
703 
failure.  
704 
 
705 
6.2.3 30-day mortality 
706 
Survival until 30 days will be analyzed using survival analysis. Participants lost to follow-up will be 
707 
censored and the censoring will be assumed non-informative. Results will be presented with 
708 
Kaplan-Meier curves and the groups compared using the log-rank test.75 Hazard ratios with 95% 
709 
confidence intervals will be obtained using Cox’s proportional hazards models.76 The proportional 
710 
hazards assumption will be verified by visual inspection of the Kaplan-Meier curves and statistically 
711 
by including a product term (i.e. “interaction”) between the treatment group variable and the natural 
712 
logarithm of time in the model.77 If the proportional hazards assumption is not met, only the Kaplan-
713 
Meier curves and the p-value from the log-rank test will be presented. 
714 
 
715 
Adverse events and other binary outcomes will be presented and analyzed like renal failure. 
716 
 
717 
6.2.4 Additional Secondary Analyses 
718 
Both ICU and hospital length of stay will be compared using Wilcoxon Rank Sum tests. Ventilator 
719 
and shock free days over the first 7-days after enrollment will likewise be compared using the 
720 


 
Wilcoxon Rank Sum given that the data will likely be not normally distributed. In these latter two 
721 
analyses, patients who expire prior to 7-days will be assessed to have 0 ventilator or shock free 
722 
days if they had died while on a ventilator or vasopressor respectively. The incidence of delirium will 
723 
be compared using the Fisher’s exact test. For the quality-of-life outcome (i.e. 90-day SF-36), the 
724 
primary analysis will only include patients with available data. As a secondary analysis, multiple 
725 
imputation will be used to estimate SF-36 scores in all patients not known to be dead at 90 -days. 
726 
 
727 
6.2.5 Subgroup analyses  
728 
The analysis will include three pre-defined subgroup analyses for the primary and key secondary 
729 
outcomes according to 1) participants with initially high SOFA scores (≥9). This cut-off was chosen 
730 
to represent a population with a ≥50% predicted likelihood of mortality78 2) baseline vitamin B1 
731 
deficiency and 3) baseline adrenal insufficiency. We will not plan to perform a subgroup analysis 
732 
according to vitamin C deficiency, as prior work has shown that the vast majority of participants with 
733 
septic shock have vitamin C levels below the reference range.36 Vitamin B1 deficiency will be 
734 
defined as a plasma vitamin B1 level ≤ 7 nmol/L as has been previously described.37 Adrenal 
735 
insufficiency will be defined as a cortisol level <10µg/dL.43 The trial is not powered to detect 
736 
subgroup differences and these will be considered exploratory and hypothesis generating.    
737 
 
738 
6.2.6 Statistical stopping criteria  
739 
Since the primary outcome is not mortality, there will be no formal stopping criteria for efficacy. 
740 
There will be no predefined stopping criteria for futility since enrollment of the full cohort might allow 
741 
for detection of efficacy in subgroups or in other outcomes even if the primary outcome is negative.  
742 
 
743 
7. DATA COLLECTION AND MANAGEMENT  
744 
7.1 Data collection process  
745 
Data collection will be the responsibility of the individual site investigators with oversite from the trial 
746 
coordinating center. Most variables (i.e. demographics, sepsis characteristics and laboratory 
747 
results) will be obtained prospectively from the electronic medical record. 30-day follow-up 
748 
regarding safety and mortality end-points will be obtained via telephone call post-discharge (unless 
749 
the participant remains in the hospital at 30-days). Data will be entered directly into the online 
750 
database software (see below).  
751 
 
752 
7.2 Variables 
753 
Will be provided on the online CRF. A PDF version is available upon request. 
754 
 
755 
7.3 Data quality and validity  
756 
Data quality and validity will be optimized by using a detailed data dictionary which will be 
757 
distributed to all sites. Data quality will be monitored both centrally by the coordinating site and 
758 
locally by each site principal investigator.  
759 
 
760 
7.4 Data storage and security  
761 
The database application we will use is REDCap Cloud (https://www.redcapcloud.com/). REDCap 
762 
Cloud is a professional database that provides a user-friendly interface. The REDCap Cloud data 
763 
management system is secure, fully compliant with all regulatory guidelines, and includes a 
764 
complete audit-trail for data entry validation. Through these mechanisms, as well as relevant 
765 
training for all involved parties, participant confidentiality will be safeguarded. All members of the 
766 
research team will be required to complete standardized training in REDCap cloud, which will be 
767 
documented within the software.  
768 
 
769 
The consent form and other trial documents for each participant will initially be stored in a secure, 
770 
locked place at the individual sites. Participating sites will be responsible for maintaining their own 
771 
trial documents and study materials (e.g. signed ICFs, site logs etc). Trial documents generated at 
772 
the Coordinating Center will be maintained the Coordinating Center. Following completion of the 
773 


 
trial, documents will be maintained for a period of at least 2-years at each site per FDA regulations 
774 
(or longer depending on local IRB guidelines). 
775 
 
776 
8. ETHICAL CONSIDERATIONS  
777 
8.1 Risks and Benefits  
778 
8.1.1 Potential benefits 
779 
Potential Benefits to Individual Participant: Assuming our hypothesis is correct and our results are 
780 
comparable to those previously published36, individual participants enrolled in our study and 
781 
randomized to the treatment arm will benefit from a better trajectory of organ failure and improved 
782 
mortality. As many participants who survive an initial episode of sepsis will have a future admission for 
783 
sepsis, participants participating in this study but randomized to the placebo arm may see a future 
784 
benefit from knowledge gained. 
785 
 
786 
Potential Benefits to Society: Septic shock remains a highly morbid clinical condition for which there 
787 
is no specific therapy. Our study, assuming our hypothesis is confirmed, will provide strong support for 
788 
the widespread adoption of vitamin C, corticosteroids, and vitamin B1 for participants with septic 
789 
shock. This, in turn, will significantly improve participant outcomes and reduce the global burden of 
790 
death related to septic shock. Thus, even if participants are randomized to the placebo arm, their 
791 
involvement with this study has tremendous potential benefits for society as whole. If vitamin C, 
792 
corticosteroids, and vitamin B1 are found to be neutral or harmful (the latter being highly unlikely), 
793 
society will benefit as the study will likely prevent the widespread dissemination of an ineffective 
794 
medication combination.  
795 
 
796 
8.1.2 Potential harms  
797 
Study Drug  
798 
Vitamin C – Ascorbic acid is a water-soluble essential vitamin that is safe even at high doses. 
799 
Nevertheless, adverse effects related to high-dose ascorbic acid have been described. These 
800 
adverse effects include diarrhea/abdominal bloating, increased oxalate excretion, iron overload in 
801 
participants with hemochromatosis, and hemolysis in participants with G6PD deficiency.79  We 
802 
exclude participants with known renal failure,  known G6PD deficiency, or known hemochromatosis 
803 
to limit these potential risks. We will additionally exclude participants with known allergy to ascorbic 
804 
acid. Ascorbic acid has additionally been used in at least 3 clinical trials in critically-ill populations 
805 
without major associated adverse effect.40-42 
806 
 
807 
Hydrocortisone – Hydrocortisone is a well-established medication for the treatment of refractory 
808 
shock in sepsis. Some studies (e.g. CORTICUS) have found an increased incidence of secondary 
809 
infection in participants with septic shock who receive steroids.46 This finding has not been 
810 
replicated in other large trials of corticosteroids for sepsis.47 Additional hypothetical risks to the 
811 
administration of hydrocortisone to participants with septic shock (e.g. increased gastro-intestinal 
812 
bleeding, muscle weakness, and delirium) have not been found in clinical trials of corticosteroids in 
813 
sepsis.46,47 Finally, hydrocortisone may increase the risk of hyperglycemia and hypernatremia.  
814 
 
815 
Hydrocortisone will not be tapered in this study as prior studies have shown benefit with 
816 
corticosteroids in septic shock without a taper.80 In addition, a recent large trial of corticosteroids in 
817 
septic shock (ADRENAL, NEJM 2018) randomized patients to 7-days of corticosteroids or placebo 
818 
and did not include a taper. In that trial there was no reported difference in rates of recurrent shock. 
819 
 
820 
Vitamin B1 – The only potential serious side effect that has been reported from vitamin B1 
821 
administration is an extremely rare anaphylactic reaction (1:250,000 cases) and this might not even 
822 
be of issue with the current manufactured version of vitamin B1 in the United States. The risk of an 
823 
anaphylactic reaction was associated with a vitamin complex dispensed in Europe, and whether 
824 


 
vitamin B1 was the actual offending agent remains unknown; however, this 0.0004% theoretical 
825 
chance of an adverse reaction is incredibly low. In a series of 989 participants in the United States 
826 
who received intravenous vitamin B1, none had an anaphylactic reaction and the only reported side 
827 
effects were minor consisting of transient local irritation or in one case pruritus (0.093%).81 Further 
828 
safety data comes from the clinical use of intravenous vitamin B1 at our coordinating site.  At Beth 
829 
Israel Deaconess Medical Center (BIDMC, coordinating center) vitamin B1 is provided liberally for 
830 
participants with nutritional deficiency – for example, BIDMC has administered intravenous vitamin 
831 
B1 in over 8,000 separate participant encounters from 2002 until present. Despite this heavy usage, 
832 
no adverse reactions were reported in any of the 8,000 participant encounters.    
833 
 
834 
The combination of vitamin C, hydrocortisone and vitamin B1 – To date, the only study of the 
835 
combination of vitamin C, hydrocortisone and vitamin B1 was the above referenced study by Marik 
836 
et. al.  
837 
 
838 
All procedures will take place at the study site. All research procedures and monitoring will be 
839 
conducted by experienced personnel, and participants will be in the ICU given critical illness. This 
840 
permits closer observation and more detailed monitoring by clinicians familiar with the care of 
841 
participants experiencing and resuscitated from septic shock. 
842 
 
843 
Blood Collection 
844 
Most participants will have existing venous or arterial catheters in place and we will be able to collect 
845 
blood from these ports, essentially eliminating the risks associated with blood collection. In the very 
846 
rare case that a participant does not have an indwelling line, the risk of venipuncture is extremely 
847 
low, and will not exceed the risk of clinical blood draws the participant will already be receiving. 
848 
 
849 
Loss of Confidentiality 
850 
All measures will be taken to ensure that no confidential information is released. All participant 
851 
information will be stored in a password protected database to which only study investigators will 
852 
have access. Additionally, all hard copies of study data will be kept in a locked office accessible only 
853 
to study investigators. Thus, the risk of loss of confidentiality is very low. 
854 
 
855 
9. MONITORING 
856 
9.1 Institutional Review Board (IRB) 
857 
The study will be reviewed and approved by the IRB at each participating site.  
858 
 
859 
9.2 Data Safety and Monitoring Board (DSMB) 
860 
The DSMB will be responsible for safeguarding the interests of trial participants, assessing the 
861 
safety and efficacy of the interventions during the trial, and for monitoring the overall conduct of the 
862 
clinical trial. The DSMB will consist of three clinicians with critical care experience in the 
863 
management of septic participants. An independent biostatistician/epidemiologist will prepare all 
864 
DSMB reports. The DSMB members will be chosen such to avoid any financial or intellectual 
865 
conflicts of interest. The DSMB will review deidentified data after every 50 participants are enrolled 
866 
to assess for safety; unless there are group differences necessitating unblinding (as determined by 
867 
the DSMB), the DSMB will be blinded to treatment groups. The trial will continue while the DSMB 
868 
review data. After each review, the DSMB will create a short report to the steering committee with 
869 
recommendations for continuation, modifications, or termination of the trial. Criteria for 
870 
recommending termination will be at the discretion of the DSMB and there will be no formal 
871 
statistical criteria for termination due to efficacy or safety. A detailed charter for the DSMB will be 
872 
provided.  
873 
 
874 
DSMB Members 
875 


 
Clifton Callaway, MD, PhD  
876 
University of Pittsburgh 
877 
400A Iroquois 
878 
Pittsburgh, PA 15260 
879 
(412) 647-8287 
880 
callawaycw@upmc.edu 
881 
Professor (tenured) of Emergency Medicine; Executive Vice-Chair of Emergency Medicine; UPMC 
882 
Professor of Emergency Medicine Research 
883 
Expertise: Cardiac Arrest/Clinical Trials  
884 
 
885 
Taylor Thompson, MD  
886 
Massachusetts General Hospital 
887 
55 Fruit Street 
888 
Boston, MA 02114 
889 
(617) 724-7823 
890 
tthompson1@partners.org 
891 
Professor of Medicine, Harvard Medical School 
892 
Director, Critical Care Translational Research, Pulmonary/Critical Care Unit, MGH 
893 
Medical Director, ARDS Network Clinical Coordinating Center  
894 
Expertise:  Sepsis/Clinical Trials 
895 
 
896 
Shahzad Shaefi, MD MPH [DSMB Chair] 
897 
Beth Israel Deaconess Medical Center 
898 
One Deaconess Raod 
899 
Boston, MA 02115 
900 
(617) 355-6286 
901 
sshaefi@bidmc.harvard.edu 
902 
Attending Physician, Department of Anesthesia, Critical Care and Pain 
903 
Expertise:  Critical Care Medicine 
904 
 
905 
10 CLINICAL MONITORING PLAN 
906 
The detailed clinical monitoring plan has been developed and is available from the Coordianting 
907 
Center upon request. 
908 


 
11. TIMELINE AND ENROLLMENT  
909 
11.1 Timeline  
910 
 
Pre-trial 
Months 0-5 
Months 6-11 
Months 12-18 
Funding 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol development and 
modifications 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FDA IND approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethical approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Registration with 
Clinicaltrials.gov 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Creation of data dictionary  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Creation of randomization 
list 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Site start-up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Education of site 
personnel  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DSMB monitoring 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrollment and 
assessment of outcomes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cleaning and closing of 
the database 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unblinding & Data analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Main manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Publication and 
presentation of results 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
911 
11.2 Screening & Enrollment  
912 
Enrollment at each site will be continuously monitored by the site investigator and the principal 
913 
investigator. Each site will be expected to maintain a screening log including all participants who 
914 
meet all eligibility criteria at that site. A standardized screening log will be provided to each site via 
915 
RedCap Cloud—thus allowing for continuous updating of the screening log and will allow capture of 
916 
all screening failures.    
917 
 
918 


 
Enrollment will be competitive (i.e. without specific enrollment caps). Number of enrollments at each 
919 
site will be shared with all sites on a monthly basis. Sites will be expected to complete all elements 
920 
of the online CRF within 48-hours of each time point. In the case that a site continuously 
921 
underperforms despite troubleshooting and feedback, the steering committee will evaluate whether 
922 
enrollment will continue at that site. 
923 
 
924 
12. FUNDING 
925 
Funding for the present trial is provided by the Good Ventures Foundation 
926 
(http://www.goodventures.org/). The funding agency will have no role in the design and conduct of 
927 
the study, collection, management, analysis, and interpretation of the data, preparation, review, or 
928 
approval of the manuscript, or the decision to submit the manuscript for publication.  
929 
 
930 
13. PUBLICATION 
931 
The manuscript will adhere to the CONSORT guidelines.72,73 The principal investigator will be 
932 
responsible for assigning authorship position and will follow authorship guidelines from the 
933 
International Committee of Medical Journal Editors.82 At a minimum, all members of the Steering 
934 
Committee and all site Principal Investigators (for sites enrolling at least 10 participants) will be 
935 
included in the primary author list. The main results will be presented at an international conference. 
936 
The trial results will be shared with participating sites and via press releases but not directly with the 
937 
participants. 
938 
 
939 
14. DATA SHARING 
940 
Six months after the publication of the last results, all de-identified individual participant data will be 
941 
made available for data sharing.83 Procedures, including re-coding of key variables, will be put in 
942 
place to allow for complete de-identification of the data. All relevant trial-related documents, 
943 
including the protocol, data dictionary, and the main statistical code, will be shared along with the 
944 
data. There will be no predetermined end date for the data sharing. Data will be available for any 
945 
research purpose to all interested parties who have approval from an independent ethics review 
946 
committee and who have a methodological sound proposal as determined by the steering 
947 
committee of the current trial. Interested parties will be able to request the data by contacting the 
948 
principal investigator. Authorship of publications emerging from the shared data will follow standard 
949 
authorship guidelines from the International Committee of Medical Journal Editors82 and might or 
950 
might not include authors from the steering committee depending on the nature of their involvement.  
951 
 
952 
15. TASKS AND RESPONSIBILITIES  
953 
Principal investigator and sponsor: Overall responsibility for protocol development, funding, budget 
954 
overview, data dictionary development, ethical approval, trial registration, daily management, trial 
955 
oversight and collection of adverse events, contact to the pharmacy, contact to Good Clinical 
956 
Practice monitoring unit and the data and safety monitoring board, assessment of overall 
957 
recruitments, potential recruitment of additional sites, data analysis, and dissemination and 
958 
presentation of results.  
959 
 
960 
Steering committee: Protocol development, funding, budget overview, data dictionary development, 
961 
trial oversight, dissemination of results, responsibilities as principal investigator for short time 
962 
periods.  
963 
 
964 
Site investigators: Responsible for site-specific enrollment, evaluation of eligible patients not 
965 
included, education of personnel at participating sites, reporting of site-specific issues or challenges 
966 
to the principal investigator, participant consent for data collection, collecting and reporting data 
967 
regarding adverse drug events. 
968 
 
969 
Clinical team: Administration of the study drug, participant consent for data collection.  
970 


 
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971 
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972 
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Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve 
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outcomes in acute kidney injury. Critical care (London, England). 2007;11(2):R31. 
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de Grooth HJ, Geenen IL, Girbes AR, Vincent JL, Parienti JJ, Oudemans-van Straaten HM. SOFA and 
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mortality endpoints in randomized controlled trials: a systematic review and meta-regression 
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analysis. Crit Care. 2017;21(1):38. 
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Schrier RW, Wang W. Acute renal failure and sepsis. The New England journal of medicine. 
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2004;351(2):159-169. 
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Kellum JA, Chawla LS, Keener C, et al. The Effects of Alternative Resuscitation Strategies on Acute 
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Kidney Injury in Patients with Septic Shock. American journal of respiratory and critical care 
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medicine. 2016;193(3):281-287. 
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63. 
Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and 
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reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Jama. 
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2001;286(21):2703-2710. 
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Watson EK, Firman DW, Baade PD, Ring I. Telephone administration of the SF-36 health survey: 
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validation studies and population norms for adults in Queensland. Aust N Z J Public Health. 
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1996;20(4):359-363. 
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65. 
Garcia M, Rohlfs I, Vila J, et al. Comparison between telephone and self-administration of Short Form 
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Health Survey Questionnaire (SF-36). Gac Sanit. 2005;19(6):433-439. 
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Schmidt K, Worrack S, Von Korff M, et al. Effect of a Primary Care Management Intervention on 
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Mental Health-Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. Jama. 
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2016;315(24):2703-2711. 
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67. 
Dinglas VD, Hopkins RO, Wozniak AW, et al. One-year outcomes of rosuvastatin versus placebo in 
1138 
sepsis-associated acute respiratory distress syndrome: prospective follow-up of SAILS randomised 
1139 
trial. Thorax. 2016;71(5):401-410. 
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68. 
Zhang K, Mao X, Fang Q, et al. Impaired long-term quality of life in survivors of severe sepsis : 
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Chinese multicenter study over 6 years. Anaesthesist. 2013;62(12):995-1002. 
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69. 
Wittbrodt P, Haase N, Butowska D, et al. Quality of life and pruritus in patients with severe sepsis 
1143 
resuscitated with hydroxyethyl starch long-term follow-up of a randomised trial. Crit Care. 
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2013;17(2):R58. 
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The European Parliament and the Council of the European Unit. Clinical Trials Regulation (CTR) EU 
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No 536/2014. 2014; https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-
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1/reg_2014_536/reg_2014_536_en.pdf. Accessed July 18, 2017. 
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Rhee C, Dantes R, Epstein L, et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs 
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Claims Data, 2009-2014. JAMA. 2017;318(13):1241-1249. 
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Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for 
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reporting parallel group randomised trials. BMJ. 2010;340:c332. 
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Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explanation and elaboration: updated 
1153 
guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c869. 
1154 
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Fergusson D, Aaron SD, Guyatt G, Hebert P. Post-randomisation exclusions: the intention to treat 
1155 
principle and excluding patients from analysis. BMJ. 2002;325(7365):652-654. 
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75. 
Fleming T, Harrington D. Nonparametric estimation of the survival distribution in censored data. 
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Communications in Statistics - Theory and Methods. 1984;13(20):2469–2486. 
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Cox D. Regression models and life tables. Journal of the Royal Statistical Society. 1972;Series 
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B(20):187–220. 
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77. 
Kleinbaum D, Klein M. Survival Analysis: A Self-Learning Text. 3rd ed: Springer; 2013. 
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Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ 
1162 
dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working 
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group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Critical care 
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medicine. 1998;26(11):1793-1800. 
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Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C 
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intake. Jama. 1999;281(15):1415-1423. 
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Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and 
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fludrocortisone on mortality in patients with septic shock. Jama. 2002;288(7):862-871. 
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81. 
Wrenn KD, Murphy F, Slovis CM. A toxicity study of parenteral thiamine hydrochloride. Annals of 
1170 
emergency medicine. 1989;18(8):867-870. 
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82. 
International Committee of Medical Journal Editors. Defining the Role of Authors and Contributors. 
1172 
2017; http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-
1173 
of-authors-and-contributors.html. Accessed July 6, 2017. 
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Taichman DB, Sahni P, Pinborg A, et al. Data Sharing Statements for Clinical Trials - A Requirement of 
1175 
the International Committee of Medical Journal Editors. N Engl J Med. 2017;376(23):2277-2279. 
1176 


 
Appendices 
1177 
 
1178 
Appendix 1: Abbreviations 
1179 
ICH………………..International Conference on Harmonization 
1180 
SPIRIT………………..Standard Protocol Items: Recommendations for Interventional Trials  
1181 
ACT………………..Ascorbic Acid, Corticosteroids, and Thiamine  
1182 
ESRD………………..End Stage Renal Disease 
1183 
SOFA………………..Sequential Organ Failure Assessment 
1184 
IND………………..Investigational New Drug 
1185 
FDA………………..Food and Drug Administration 
1186 
ICU………………..Intensive Care Unit 
1187 
SaO2………………..Oxygen Saturation 
1188 
FiO2………………..Fraction of Inspired Oxygen 
1189 
GCS………………..Glasgow Coma Scale 
1190 
UOP………………..Urine Output 
1191 
RRT………………..Renal Replacement Therapy 
1192 
CAM………………..Confusion Assessment Method 
1193 
NCHS……………….. National Center for Health Statistics 
1194 
NDI………………..National Death Index 
1195 
AKI………………..Acute Kidney Injury 
1196 
SD……………….. tandard deviation 
1197 
CRF………………..Case Report Form 
1198 
BIDMC………………..Beth Israel Deaconess Medical Center (Coordinating Center) 
1199 
IRB………………..Institutional Review Board 
1200 
DSMB………………..Data Safety and Monitoring Board 
1201 
 
1202 
 
1203 
 
1204 
 
1205 
 
1206 
 
1207 
 
1208 
 
1209 
 
1210 
 
1211 
 
1212 
 
1213 
 
1214 
 
1215 
 
1216 
 
1217 
 
1218 
 
1219 
 
1220 
 
1221 
 
1222 
 
1223 
 
1224 


 
Appendix 2: CAM-ICU Form 
1225 
 
1226 
 
1227 
 
1228 


 
2. PROTOCOL V2.1 (ORIGINAL) 
1229 
Ascorbic Ccid, Hydrocortisone, and Thiamine in Sepsis and Septic Shock 
1230 
– A Randomized, Double-Blind, Placebo-Controlled Trial 
1231 
 
1232 
Acronym: Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) Trial 
1233 
 
1234 
CLINICAL TRIAL PROTOCOL 
1235 
 
1236 
             Version 2.1 
1237 
February 2nd, 2018 
1238 
            IND: 136882 
1239 
 
1240 
 
1241 
Clinical Trials.Gov Identifier: NCT03389555 
1242 
 
1243 
Principal investigator: 
1244 
Michael W. Donnino, MD 
1245 
Director of Center for Resuscitation Science 
1246 
Associate Professor of Medicine, Harvard Medical School 
1247 
Attending Physician in Emergency and Critical Care Medicine, BIDMC 
1248 
 
1249 
Beth Israel Deaconess Medical Center 
1250 
West Clinical Campus 2nd Floor 
1251 
One Deaconess Road, Boston MA 02215 
1252 
Phone: 617-754-2295 
1253 
Fax: 617-754-2350 
1254 
Email: mdonnino@bidmc.harvard.edu 
1255 
 
1256 
Funded By: 
1257 
Open Philanthropy Project (https://www.openphilanthropy.org/) 
1258 
 
1259 
 
1260 
 
1261 
 
1262 
 
1263 
 
1264 
 
1265 
 
1266 
 
1267 
 
1268 
 
1269 
 
1270 
 
1271 


 
 
1272 
SYNOPSIS ...................................................................................................................................................... 38 
1273 
TRIAL OVERVIEW ......................................................................................................................................... 39 
1274 
STEERING COMMITTEE ............................................................................................................................. 40 
1275 
TRIAL SITES ................................................................................................................................................... 41 
1276 
1. BACKGROUND AND SIGNIFICANCE ................................................................................................... 42 
1277 
1.1 Scope of the Problem .......................................................................................................................... 42 
1278 
1.2 Existing Interventions .......................................................................................................................... 42 
1279 
1.3 The combination of vitamin C, hydrocortisone, and vitamin B1 may improve outcomes ......... 42 
1280 
1.4 Physiologic Rationale .......................................................................................................................... 42 
1281 
2. TRIAL DESIGN ........................................................................................................................................... 43 
1282 
2.1 Overview ................................................................................................................................................ 43 
1283 
2.2 Allocation ............................................................................................................................................... 43 
1284 
2.3 Intervention ........................................................................................................................................... 43 
1285 
2.3.1 Vitamin C, Hydrocortisone, and Vitamin B1 ............................................................................. 43 
1286 
2.3.2 Placebo........................................................................................................................................... 43 
1287 
2.4 Blinding .................................................................................................................................................. 43 
1288 
2.5 Regulatory Issues ................................................................................................................................. 43 
1289 
3.  SETTING AND PARTICIPANT POPULATION .................................................................................... 44 
1290 
3.1 Setting .................................................................................................................................................... 44 
1291 
3.2 Inclusion criteria ................................................................................................................................... 44 
1292 
3.3 Exclusion criteria .................................................................................................................................. 44 
1293 
3.4 Pregnancy ............................................................................................................................................. 44 
1294 
4. TRIAL PROCEDURES .............................................................................................................................. 45 
1295 
4.1 Participant Identification ...................................................................................................................... 45 
1296 
4.2 Consent proecdures ............................................................................................................................ 45 
1297 
4.3 Randomization ...................................................................................................................................... 45 
1298 
4.4 Drug preparation and administration ................................................................................................. 45 
1299 
4.4.1 Contingencies and Participant Withdrawal ............................................................................... 45 
1300 
4.5 Specimen collection procedures ........................................................................................................ 46 
1301 
4.5.1 Timing and volume of blood draw .............................................................................................. 46 
1302 
4.5.2 Specimen samples ....................................................................................................................... 46 
1303 
4.5.3 Biomarker tube initial processing and shipping ........................................................................ 46 
1304 
4.6 Study flow diagram .............................................................................................................................. 47 
1305 
4.7 General Sepsis Management ............................................................................................................. 47 
1306 


 
4.8 Glucometer use during the study period .......................................................................................... 47 
1307 
5. OUTCOMES ............................................................................................................................................... 47 
1308 
5.1 Definitions .............................................................................................................................................. 47 
1309 
5.1.1 Primary Outcome .......................................................................................................................... 47 
1310 
5.1.2 Key Secondary Outcomes ........................................................................................................... 48 
1311 
5.2 Rationale for Outcomes ...................................................................................................................... 48 
1312 
5.3 Additional Secondary Outcomes ....................................................................................................... 49 
1313 
5.3.1 Additional secondary outcomes .................................................................................................. 49 
1314 
5.3.2 90-day follow-up for Quality of Life assessment ...................................................................... 49 
1315 
5.4 Safety ..................................................................................................................................................... 49 
1316 
5.4.1 Definitions ...................................................................................................................................... 49 
1317 
5.4.2 Specific adverse event data collection ...................................................................................... 50 
1318 
5.4.3 Adverse Event Reporting ............................................................................................................. 50 
1319 
5.4.5 Safety Monitoring Labs ................................................................................................................ 50 
1320 
6. SAMPLE SIZE CALCULATION AND STATISTICAL ANALYSIS PLAN ........................................... 50 
1321 
6.1 Sample size calculation ....................................................................................................................... 50 
1322 
6.2 Statistical analysis plan ....................................................................................................................... 51 
1323 
6.2.1 General considerations ................................................................................................................ 51 
1324 
6.2.2 SOFA score and renal failure...................................................................................................... 51 
1325 
6.2.3 30-day mortality ............................................................................................................................. 51 
1326 
6.2.5 Subgroup analyses ....................................................................................................................... 52 
1327 
6.2.6 Statistical stopping criteria ........................................................................................................... 52 
1328 
7. DATA COLLECTION AND MANAGEMENT .......................................................................................... 52 
1329 
7.1 Data collection process ....................................................................................................................... 52 
1330 
7.2 Variables ................................................................................................................................................ 52 
1331 
7.3 Data quality and validity ...................................................................................................................... 52 
1332 
7.4 Data storage and security ................................................................................................................... 52 
1333 
8. ETHICAL CONSIDERATIONS ................................................................................................................. 53 
1334 
8.1 Risks and Benefits ............................................................................................................................... 53 
1335 
8.1.1 Potential benefits .......................................................................................................................... 53 
1336 
8.1.2 Potential harms ............................................................................................................................. 53 
1337 
9. MONITORING ............................................................................................................................................. 54 
1338 
9.1 Institutional Review Board (IRB) ........................................................................................................ 54 
1339 
9.2 Data Safety and Monitoring Board (DSMB) ..................................................................................... 54 
1340 
10 CLINICAL MONITORING PLAN ............................................................................................................. 55 
1341 


 
11. TIMELINE AND ENROLLMENT ............................................................................................................ 56 
1342 
11.1 Timeline ............................................................................................................................................... 56 
1343 
11.2 Screening & Enrollment .................................................................................................................... 56 
1344 
12. FUNDING .................................................................................................................................................. 57 
1345 
13. PUBLICATION .......................................................................................................................................... 57 
1346 
14. DATA SHARING ...................................................................................................................................... 57 
1347 
15. TASKS AND RESPONSIBILITIES ........................................................................................................ 57 
1348 
References ...................................................................................................................................................... 58 
1349 
Appendices ...................................................................................................................................................... 63 
1350 
Appendix 1: Abbreviations ......................................................................................................................... 63 
1351 
Appendix 2: CAM-ICU Form ..................................................................................................................... 64 
1352 
 
1353 


 
SYNOPSIS 
1354 
 
1355 
The “Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis (ACTS)” trial is a multi-center, double-
1356 
blind, randomized clinical trial that aims to determine the impact of Vitamin C, Hydrocortisone, and 
1357 
Vitamin B1 vs. Placebo on organ injury and mortality on participants with sepsis and septic shock. 
1358 
The trial will be conducted in accordance with all applicable national and international laws, 
1359 
regulations, and guidelines The trial and this protocol is developed in accordance with the 
1360 
International Conference on Harmonization (ICH) guidelines1-3 and the Standard Protocol Items: 
1361 
Recommendations for Interventional Trials (SPIRIT) statement4,5. The principal investigator wrote 
1362 
the protocol with input from the steering committee. Any substantial changes or amendments to the 
1363 
protocol will be clearly documented and communicated to all relevant parties.  
1364 
 
1365 


 
TRIAL OVERVIEW 
1366 
 
1367 
Title 
Vitamin C, Hydrocortisone, and Vitamin B1 in Sepsis and 
Septic Shock – A Randomized, Double-Blind, Placebo-
Controlled Trial (The ACTS Trial) 
Clinical Trials Number 
NCT03389555 
Sources of monetary or 
material support 
Open Philanthropy Project 
(https://www.openphilanthropy.org/)  
Study Sites 
12-sites in the United States 
Condition studied 
Sepsis and septic shock 
Interventions 
Vitamin C (1.5g every 6 hours x 4-days), hydrocortisone 
(50mg every 6 hours x 4-days), and Vitamin B1 (100mg 
every 6 hours x 4-days) 
Comparator  
Placebo  
Inclusion criteria 
 Adult participant (age ≥ 18 years) 
 Suspected (cultures drawn and antibiotic given) or 
confirmed (via culture results) infection 
 Receiving vasopressor (norepinephrine, 
phenylephrine, epinephrine, dopamine, vasopressin, or 
angiotensin II)  
Exclusion criteria 
 Member of a protected population (pregnant, prisoner) 
 Known history of kidney stones within the past 1 year 
 Known history of chronic kidney disease (CKD stage 
≥3b [GFR < 45ml/hr]) 
 Known history of G6PD deficiency 
 Known history of Hemochromatosis 
 Comfort Measures Only status 
 Anticipated death within 24-hours despite maximal 
therapy (as determined by the enrolling physician) 
 Receiving supplemental vitamin B1 in a dose greater 
than that contained in a multivitamin (<2mg) 
 Clinical indication for steroids (e.g. chronic use) as 
determined by the clinical team providing this drug 
 Clinical indication for vitamin B1 as determined by the 
clinical team providing this drug 
 Known allergy to vitamin C, hydrocortisone, or vitamin 
B1 
Study type 
Interventional 
Allocation: Randomized (1:1) 
Intervention model: Parallel group 
Masking: Double-blind 
Target sample size 
200 Participants (100/arm) 
Primary outcome 
Change in the Sequential Organ Failure Assessment 
(SOFA) score between enrollment and 72-hours 
Key secondary outcomes 
Incidence of renal failure during index ICU stay 
30-day mortality 


 
STEERING COMMITTEE 
1368 
 
1369 
Michael Donnino, M.D.  
Associate Professor of Medicine 
Director, Center for Resuscitation Science  
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Paul E. Marik, M.D. 
Professor of Medicine 
Chief, Division of Pulmonary and Critical 
Care Medicine 
Eastern Virginia Medical School 
Ari Moskowitz, M.D. 
Attending, Pulmonary and Critical Care Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Katherine Berg, M.D. 
Assistant Professor of Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Lars W. Andersen, M.D., MPH, Ph.D 
Associate Professor of Medicine 
Research Center for Emergency Medicine 
Department of Clinical Medicine 
Aarhus University and Aarhus University Hospital 
Anne Grossestreuer, Ph.D. 
Instructor in Emergency Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Michael N. Cocchi, MD 
Assistant Professor of Emergency Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Joseph Miller, MD 
Attending, Emergency Medicine 
Department of Emergency Medicine 
Henry Ford Hospital 
Conflicts of interest 
1370 
The members of the steering committee have no financial conflicts of interest related to the current 
1371 
trial.  
1372 


 
TRIAL SITES 
1373 
 
1374 
Coordinating Center 
1375 
Beth Israel Deaconess Medical Center 
1376 
330 Brookline Avenue 
1377 
Boston, MA 02215 
1378 
Site Investigator: Michael W. Donnino, MD 
1379 
 
1380 
Enrolling Sites* 
1381 
 
1382 
Hospital Name 
Location 
Site Principal Investigator 
Henry Ford Hospital 
Detroit, MI 
Joseph Miller, MD 
DMC-Detroit Receiving Hospital 
Detroit, MI 
Rob Sherwin, MD 
DMC-Sinai-Grace Hospital 
Detroit, MI 
Rob Sherwin, MD 
UT Health, The University of Texas 
Health Science Center 
Houston, TX 
Pratik Doshi, MD 
Mayo Clinic 
Phoenix, AZ 
Ayan Sen, MD 
Beth Israel Deaconess Medical 
Center 
Boston, MA 
Ari Moskowitz, MD 
Beaumont Hospital 
Royal Oak, MI 
Ron Otero, MD 
Brigham and Women’s Hospital 
Boston, MA 
Peter Hou, MD 
Long Island Jewish Hospital Center 
- Queens 
New York, NY 
Maksim Korotun, MD 
Long Island Jewish Hospital Center 
– Hyde Park 
New York, NY 
Ayelet Hilewitz, MD 
Mount Auburn Hospital 
Cambridge, MA 
Jessica McCannon, MD 
Univerity of Pittsburgh 
Pittsburgh, PA 
David Huang, MD 
*Depending on study progress, sites may be added or removed in the future. 
1383 
 
1384 
 
1385 
 
1386 
 
1387 
 
1388 
 
1389 
 
1390 
 
1391 
 
1392 
 
1393 
 
1394 
 
1395 
 
1396 
 
1397 
 
1398 
 
1399 
 
1400 
 
1401 
 
1402 
 
1403 
 
1404 
 
1405 


 
3. BACKGROUND AND SIGNIFICANCE 
1406 
1.1 Scope of the Problem  
1407 
The worldwide incidence of sepsis has been estimated at more than 23 million cases6 and sepsis 
1408 
contributes to more than a third of all hospital deaths in the United States.7,8 Mortality for those in 
1409 
septic shock with elevated lactate is more than 40%.9 In addition to high short-term mortality, sepsis 
1410 
is associated with significant post-discharge morbidity and mortality.10-15 The economic burden for 
1411 
participants suffering from sepsis is staggering with an estimated yearly financial burden of $17 
1412 
billion.16 Treatments are generally limited to antibiotics and intravenous fluids while providing 
1413 
support to maintain organ function.17,18  
1414 
 
1415 
1.2 Existing Interventions 
1416 
To date, numerous interventions have been tested for participants with sepsis and septic shock with 
1417 
limited, if any, success.19-22 Recently, three large studies found no benefit from early goal directed 
1418 
therapy over usual care in emergency department participants with sepsis.23-25 Other recent studies 
1419 
focusing on hemodynamics, fluid therapy, and transfusions have also failed to show a significant 
1420 
benefit in this participant population.26-28 Previous studies focusing on immunomodulary therapies or 
1421 
drotrecogin alfa have likewise shown disappointing results.29-35  
1422 
 
1423 
1.3 The combination of vitamin C, hydrocortisone, and vitamin B1 may improve outcomes  
1424 
In a before-and-after study exploring the effects of the combination of vitamin C, hydrocortisone, and 
1425 
vitamin B1 in a cohort of participants with sepsis and septic shock, Marik et. al. found a remarkable 
1426 
improvement in time to shock reversal (18.3 ± 9.8 hours vs. 54.9 ± 28.4 hours), organ injury (ΔSOFA 
1427 
4.8 ± 2.4 vs. 0.9 ± 2.7), and mortality (8.5% vs. 40.4%) following implementation of the drug ‘cocktail’ 
1428 
as compared to before implementation even after adjusting for potential confounders.36 This study 
1429 
joins other promising trials of individual elements of this drug combination. In a trial of vitamin B1 in 
1430 
septic shock, there was a substantial reduction in mortality and organ injury (particularly kidney 
1431 
injury) in those with vitamin B1 deficiency and septic shock who were given vitamin B1 as compared 
1432 
to placebo.37,38 In addition, several studies of vitamin C alone have shown promise in critically ill 
1433 
populations39-42 and a recent meta-analysis of corticosteroids in sepsis suggests potential benefit.43 
1434 
 
1435 
1.4 Physiologic Rationale 
1436 
The combination of vitamin C, hydrocortisone, and vitamin B1 is hypothesized to improve outcomes 
1437 
in sepsis through a number of mechanisms.36 Vitamin C is an important contributor to endothelial 
1438 
integrity and severe deficiency states (e.g. scurvy) can result in endothelial breakdown with resultant 
1439 
vascular leak and edema.44,45  In addition, vitamin C is a potent anti-oxidant and is integral to 
1440 
endogenous vasopressor synthesis.36 Hydrocortisone, a potential adjunctive therapy in septic 
1441 
shock46,47, may act synergistically with vitamin C.48,49 Vitamin B1, a key cofactor of pyruvate 
1442 
dehydrogenase, is a critical component of metabolic dysfunction without which a shift towards 
1443 
anaerobic energy production occurs.50 Vitamin B1 is also a necessary component of the pentose 
1444 
phosphate pathway, which plays a role in reducing oxidative stress.51,52 While the physiologic effects 
1445 
of these drugs given in combination is not entirely known, we hypothesize that there will be 
1446 
synergistic effects with respect the metabolic resuscitation of sepsis.  
1447 


 
4. TRIAL DESIGN 
1448 
2.1 Overview 
1449 
This will be an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, 
1450 
double-blind, superiority trial of vitamin C, hydrocortisone, and vitamin B1 vs. placebo in participants 
1451 
with sepsis and septic shock. A total of 200 adult participants will be enrolled. The primary outcome 
1452 
will be the change in SOFA score between enrollment and 72-hours. Key secondary outcomes 
1453 
include the incidence of renal failure during the index ICU stay and survival at 30 days. 
1454 
 
1455 
2.2 Allocation 
1456 
Participants will be randomized in a 1:1 ratio to either the combination of vitamin C, hydrocortisone, 
1457 
and vitamin B1 or placebo in blocks with random sizes of 2 or 4. The randomization will be stratified 
1458 
according to site.53 An independent statistician will create the randomization list using a random 
1459 
number generator. The complete list will only be shared with an independent pharmacy consultant, 
1460 
who will not be involved in clinical care. The pharmacy consultant and the independent statistician 
1461 
will both store the randomization list. The research pharmacy at each enrolling site will receive a 
1462 
site-specific randomization list.   
1463 
 
1464 
2.3 Intervention 
1465 
2.3.1 Vitamin C, Hydrocortisone, and Vitamin B1 
1466 
The study drugs will consist of vitamin C (1.5g every 6 hours x 4-days), hydrocortisone (50mg every 6 
1467 
hours x 4-days), and vitamin B1 (100mg every 6 hours x 4-days). 
1468 
 
1469 
2.3.2 Placebo  
1470 
The placebo will consist of matching volumes of normal saline (0.9% NaCl). See below section 4.4 
1471 
for specifics of drug and placebo preparation.  
1472 
 
1473 
2.4 Blinding  
1474 
The trial will be double-blind; participants, investigators, and the clinical team will be blinded to the 
1475 
allocation. Only the pharmacy providing the study drug will be aware of the allocation. The 
1476 
pharmacy will not be involved with clinical care or outcome evaluation.  
1477 
 
1478 
As vitamin C possess a yellow tinge, the bags containing the vitamin C/placebo will be covered with 
1479 
light-protective bags. In testing, after dilution there is not distinguishing characteristics of the vitamin 
1480 
C vs. placebo in the IV tubing. Vitamin C, hydrocortisone, and vitamin B1 are not known to have 
1481 
distinctive rapid effects which could lead to unblinding.  
1482 
 
 
1483 
The decision to unblind will be at the complete discretion of the treating physician and clinical team. 
1484 
If a clinical team wishes to unblind a participant (e.g. if anaphylaxis occurs), they will contact the 
1485 
research pharmacy who will reveal the study group to the clinical team (but the research team will 
1486 
remain blinded). However, we do not expect many scenarios where emergency unblinding will be 
1487 
necessary. In case unblinding occurs, the reason(s) will be clearly documented in the case report 
1488 
form. The patient will no longer receive study medications, but will be followed for outcomes.  
1489 
 
1490 
4.5 Regulatory Issues 
1491 
An Investigational New Drug (IND) application was submitted to and approved by the Food and 
1492 
Drug Administration (FDA) for the study of vitamin C, hydrocortisone, and vitamin B1 in sepsis and 
1493 
septic shock (IND # 136882). 
1494 
 
1495 
The trial has been registered on ClinicalTrials.gov: NCT03389555 
1496 
 
1497 
 
1498 


 
3.  SETTING AND PARTICIPANT POPULATION 
1499 
3.1 Setting 
1500 
The trial will be conducted at 12 hospitals in the United States. Additional sites might be recruited if 
1501 
needed.  
1502 
 
1503 
3.2 Inclusion criteria 
1504 
Inclusion criteria:  
1505 
4) Adult participant (age ≥ 18 years) 
1506 
5) Suspected (cultures drawn and antibiotic given) or confirmed (via culture results) infection 
1507 
6) Receiving (continuous infusion) vasopressor (norepinephrine, phenylephrine, epinephrine, 
1508 
dopamine, or vasopressin)  
1509 
 
1510 
3.3 Exclusion criteria  
1511 
Exclusion criteria: 
1512 
13) Member of a protected population (pregnant, prisoner) 
1513 
14) Known history of kidney stones within the past 1 year (not including incidentally noted stones 
1514 
noted on imaging studies) 
1515 
15) Known history of chronic kidney disease (CKD stage ≥3b [GFR < 45ml/hr]) 
1516 
16) Known history of G6PD deficiency 
1517 
17) Known history of Hemochromatosis 
1518 
18) Comfort Measures Only status 
1519 
19) Anticipated death within 24-hours despite maximal therapy (as determined by the enrolling 
1520 
physician) 
1521 
20) Receiving supplemental vitamin B1 in a dose greater than that contained in a multivitamin 
1522 
(<2mg) 
1523 
21) Clinical indication for steroids (e.g. chronic use) as determined by the clinical team providing 
1524 
this drug 
1525 
22) Clinical indication for vitamin B1 as determined by the clinical team providing this drug 
1526 
23) Known allergy to vitamin C, hydrocortisone, or vitamin B1 
1527 
 
1528 
 
1529 
Justification of Inclusion and Exclusion Criteria: The inclusion criteria were chosen to isolate a septic 
1530 
participant population with high risk of organ injury and death. The exclusion criteria were chosen to 
1531 
minimize the risk of potential harm and to ensure that participants enrolled do not already have 
1532 
chronic end-stage renal failure with a high likelihood of early need for renal replacement therapy. By 
1533 
evaluating this high-risk population (i.e., most likely to die), we will target those most likely to benefit 
1534 
and therefore increase the probability of showing efficacy.19  
1535 
 
1536 
3.4 Pregnancy 
1537 
Hydrocortisone is considered pregnancy class C on the basis of animal studies showing an 
1538 
association between prenatal parenteral hydrocortisone use and risk of cleft-palate. In addition, 
1539 
there are concerns about effects of hydrocortisone on fetal growth and the possibility of neonatal 
1540 
adrenal insufficiency. The effects of high-dose vitamin C and thiamine in pregnancy are not entirely 
1541 
known. As such, participants who are pregnant will be excluded from the study. Prior to enrollment, 
1542 
all participants of potentially child-bearing potential (women aged <45 years54) will be required to 
1543 
have a negative serum or urine HCG test (generally performed as standard-of-care).  
1544 
 
1545 
We will additionally inform all women of child-bearing potential who are randomized in this study 
1546 
that we recommend they remain abstinent or use two forms of birth control during the study period 
1547 
and for a period of 48-hours after the last dose of study drug.  
1548 


 
4. TRIAL PROCEDURES 
1549 
4.1 Participant Identification  
1550 
Screening will be performed in the emergency department and intensive care units (ICUs) with the 
1551 
assistance of electronic screening mechanisms . Detailed screening logs, with reason(s) for 
1552 
exclusion will be kept at each site and reported in the final publication.  
1553 
 
1554 
We anticipate that all patients, as part of standard-of-care for the septic patient, will have a urine or 
1555 
serum HCG test performed (if a female of child-bearing age). If this test is not sent as part of 
1556 
standard-of-care, it should be sent prior to consent.   
1557 
 
1558 
4.2 Consent proecdures 
1559 
Informed, written consent will be obtained for all participants prior to enrollment.  
1560 
 
1561 
After it is determined that they meet all inclusion criteria and no exclusion criteria, the participant (or 
1562 
legally authorized representative [LAR] if the participant is not able to provide consent) will be 
1563 
approached for written informed consent by a physician co-investigator from the team. The 
1564 
investigator will provide the participant/representative information regarding the background and 
1565 
significance of the study, eligibility criteria, and a description of the protocol. To ensure we are 
1566 
correctly identifying the potential participant’s LAR, we communicate with members of the clinical 
1567 
team. The consent process may need to be modified based on site-specific IRB recommendations.  
1568 
 
1569 
The name of the study investigator obtaining consent will be clearly documented, and this person 
1570 
will sign the informed consent document and provide the date and time of their signature. If a 
1571 
physician is performing remote consent, then a copy of the consent form will be signed as soon as 
1572 
he/she is physically present. Signed copies of the consent form will be given to the 
1573 
participant/surrogate, and the original consent document will be stored in the secure study file. In 
1574 
obtaining and documenting informed consent, each investigator will comply with the applicable 
1575 
regulatory requirements and adhere to the ethical and Good Clinical Practice principles that have 
1576 
their origin in the Declaration of Helsinki.  
1577 
 
1578 
4.3 Randomization 
1579 
After consent is obtained, the research team will notify the local research pharmacy. The research 
1580 
pharmacy will be in possession of the randomization list and will determine which arm (intervention 
1581 
vs. placebo) the participant will be enrolled in.  
1582 
 
1583 
4.4 Drug preparation and administration 
1584 
The vitamin C and vitamin B1 will be mixed together in 100ml of normal saline and administered 
1585 
intravenously over 45-60 minutes. The hydrocortisone will be given intravenously as a push-dose in 
1586 
1ml of saline over 1-2 minutes. The placebo will be given using techniques and volumes matching 
1587 
those of the study medications. 
1588 
 
1589 
All study medications will be continued for 4-days or until the participant expires or leaves the 
1590 
intensive care unit.  
1591 
 
1592 
4.4.1 Contingencies and Participant Withdrawal  
1593 
 In the unlikely event that a participant is discharged alive from the hospital prior to 4 days after 
1594 
enrollment, all study medications will be stopped.The participant will remain in the study and will 
1595 
be followed for outcomes. 
1596 
 Hydrocortisone is occasionally used for refractory septic shock. If the clinical team opts to provide a 
1597 
participant hydrocortisone, the hydrocortisone will be given open-label but the vitamin C/B1 will 
1598 
remain randomized and blinded. In this case, the research team will ensure that study 
1599 


 
hydrocortisone/placebo is replaced by open-label hydrocortisone. The participant will remain in 
1600 
the study and will be followed for outcomes. 
1601 
 If the clinical team decides to give the participant either vitamin B1 or vitamin C for clinical 
1602 
purposes, further administration of study meds will be stopped. The participant will remain in the 
1603 
study and will be followed for outcomes.  
1604 
 If a participant withdraws from the study, further administration of study meds will be stopped. 
1605 
Data collected prior to withdrawal will be maintained but additional data will not be collected.   
1606 
 
1607 
4.5 Specimen collection procedures 
1608 
4.5.1 Timing and volume of blood draw 
1609 
All participants will have a blood samples collected at four time-points and urine samples at two 
1610 
time-points (if not already available as part of routine clinical care). Blood will be obtained by 
1611 
venipuncture, or from an existing venous or arterial catheter. Urine will be collected via clean catch 
1612 
urine or via catheter.  
1613 
 
1614 
Specimen Collection Time Points 
1615 
1. T1=0 hrs (just before study drug administration) 
1616 
2. T2=24 hrs (+/- 2 hrs) 
1617 
3. T3=72 hrs (+/- 2 hrs) 
1618 
4. T4=120hrs (+/- 12hrs) 
1619 
 
1620 
4.5.2 Specimen samples 
1621 
At the T1, T2, T3, and T4 time points, blood will be sent for complete blood count (including 
1622 
hemoglobin, white blood cell count, platelet count), a serum chemistry (including sodium, 
1623 
potassium, chloride, bicarbonate, blood urea nitrogen, creatining, glucose, aspartate transaminase, 
1624 
alanine transaminase, and total bilirubin), and a venous blood gas to measure lactate. These tests 
1625 
will be performed by the clinical laboratory at each site. As many of these laboratory tests are 
1626 
commonly obtained for clinical purposes, these tests do not need to be repeated if a result is 
1627 
available from the clinical care of the participant within 2 hours of the time point (or within 12 hours 
1628 
of the T4 time-point).  
1629 
 
1630 
In addition to traditional clinical markers, 25ml of blood will be obtained for future biomarker analysis 
1631 
(including inflammatory biomarkers, markers of endothelial function, and markers of mitochondrial 
1632 
function), and measurement of vitamin C, vitamin B1, and cortisol levels. Levels of vitamin C, 
1633 
vitamin B1, and cortisol will be measured at time T1 and time T3 only. 20ml of urine will be collected 
1634 
for future biomarker analysis at T1, T2, and T3. 
1635 
 
1636 
If performed as part of standard-of-care, results of urinalysis and urine sediment testing will be 
1637 
collected prior to enrollment.  
1638 
 
1639 
4.5.3 Biomarker tube initial processing and shipping 
1640 
Please see accompanying blood collection standard operating procedure for full details. In brief, 
1641 
15ml of blood will be drawn into EDTA tubes and 10ml of blood will be drawn into a corvac tube. 
1642 
From one of the EDTA tubes, 3ml of whole blood will be initially drawn and separated into 3x 1ml 
1643 
aliquots. Plasma will then be isolated from the EDTA tube(s) and aliquoted into cryovials as follows: 
1644 
2x 1ml aliquots and the remainder in 0.5ml aliquots. Serum will then be isolated from the corvac 
1645 
tube, and separated into 1ml aliquots. Cryovials will be protected from light and frozen at -80°C until 
1646 
processing. An additional 20ml of urine will also be collected, centrifuged, and separated into 1ml 
1647 
aliquots then frozen at -80°C until processing. 
1648 
 
1649 


 
Sites will be expected to ship frozen samples to the coordinating center after every 5 enrollments. 
1650 
The coordinating center will assist with all shipping procedures.  
1651 
 
1652 
4.6 Study flow diagram 
1653 
 
1654 
 
1655 
 
1656 
4.7 General Sepsis Management  
1657 
Investigators should follow local sepsis management guidelines. No specific sepsis bundle is 
1658 
required by this study, however the early administration of antibiotics, maintenance of a mean 
1659 
arterial pressure ≥65mmHg with a combination of volume resuscitation and vasopressors, and early 
1660 
source control are recommended—as detailed in the Suriving Sepsis Guidelines.55 Elements of 
1661 
sepsis care should be reported on the online case report form (CRF). 
1662 
 
1663 
4.8 Glucometer use during the study period 
1664 
High dose vitamin C has been shown to falsely elevate glucose level readings when measured with 
1665 
certain point-of-care glucometers employing glucosedehydrogenase-pyrroloquinoline quinone 
1666 
amperometric methods56. Some commonly used glucometer brands using this approach include 
1667 
Accu-Chek (Roche Diagnostic) and Optium (Abbott Diabetes Care) (but not StatStrip; Nova 
1668 
Biomedical). While the effects of high-dose vitamin C on glucometer readings have been seen 
1669 
primarily at higher doses of vitamin C than are intended for use in this trial,56 we recommend that 
1670 
sites explore what glocumeters are in use in local ICUs. If locally used glucometers may be 
1671 
impacted by high serum concentrations of vitamin C (as determined by the manufacturer), we 
1672 
recommend that clinical teams caring for enrolled participants be alerted to the possibility of falsely 
1673 
elevated blood-glucose levels when measured by glucometer. If there is a clinical concern about a  
1674 
glucose reading obtained via glucometer, a serum glucose should be obtained which will not be 
1675 
impacted by vitamin C. In the event of an emergency related to suspected hypoglycemia, glucose 
1676 
should be immediately given while a serum glucose level is pending.  
1677 
 
1678 
5. OUTCOMES 
1679 
5.1 Definitions 
1680 
5.1.1 Primary Outcome 
1681 
The primary outcome will be the absolute change in the Sequential Organ Failure Assessment 
1682 
(SOFA]) score from enrollment (time=0) to 72 hours after drug administration. The SOFA score will 
1683 
be defined using a modification in which the SaO2/FiO2 ratio is substituted for the PaO2/FiO2 ratio 
1684 


 
as has been previously described.57 This modified score will be used so that participants without an 
1685 
existing arterial catheter can be spared arterial puncture.  
1686 
 
1687 
Points 
SaO2*/FiO2§ 
Blood Pressure 
GCS‖ 
Bilirubin 
(mg/dL) 
Creatinine 
(mg/dL) 
Platelets 
(x103µL) 
1 
<512 
< 70 mm/Hg 
13–14 
1.2–1.9 
1.2 – 1.9 
<150 
2 
<357 
dopamine ≤ 5 µg/kg/min or 
dobutamine  
(any dose) 
10–12 
2–5.9 
2.0 – 3.4 
<100 
3 
<214 
dopamine > 5µg/kg/min, 
epinephrine/norepinephrine  
≤ 0.1 µg/kg/min 
6–9 
6–11.9 
3.5 – 4.9 
Or 
UOP†<500ml/day 
<50 
4 
<89 
dopamine > 15, 
epinephrine/norepinephrine 
> 0.1 µg/kg/min  
<6 
>12 
> 5.0 
UOP†<200ml/day 
<20 
*SaO2=Oxygen saturation (%); § = Fraction of inspired oxygen (%); ‖ = Glasgow Coma Scale; † = Urine Output 
1688 
 
1689 
5.1.2 Key Secondary Outcomes 
1690 
Incidence of Acute Renal Failure – Renal failure will be defined as the development of Kidney 
1691 
Disease Improving Global Outcomes [KDIGO] Stage 3 acute kidney injury during the index ICU stay 
1692 
after study enrollment.58 
1693 
 
1694 
KDIGO Stage 
Serum creatinine criteria 
Urine output criteria 
1 
Increase in serum creatinine of 
more than or equal to 0.3 mg/dl (≥ 
26.4 μmol/l) or increase to more 
than or equal to 150% to 200% (1.5- 
to 2-fold) from baseline 
Less than 0.5 ml/kg per hour for 
more than 6 hours 
2 
Increase in serum creatinine to 
more than 200% to 300% (> 2- to 3-
fold) from baseline 
Less than 0.5 ml/kg per hour for 
more than 12 hours 
3 
Increase in serum creatinine to 
more than 300% (> 3-fold) from 
baseline (or serum creatinine of 
more than or equal to 4.0 mg/dl [≥ 
354 μmol/l] with an acute 
increase of at least 0.5 mg/dl [44 
μmol/l])  
Less than 0.3 ml/kg per hour for 
24 hours or anuria for 12 hours 
OR 
New renal replacement therapy 
(RRT) 
 
1695 
30-Day Mortality – Mortality at 30-days. This will be assessed by review of the medical records if the 
1696 
participant remains in the hospital or if the participant expired while in the hospital. If the participant 
1697 
was discharged, 30-day mortality will be assessed by contacting the participant by phone or by 
1698 
searching the National Center for Health Statistics (NCHS) National Death Index (NDI) consistent 
1699 
with a recent multicenter phase III trial in sepsis.23 Phone calls will be made by the research team at 
1700 
each site.  
1701 
 
1702 
5.2 Rationale for Outcomes  
1703 
Change in SOFA score: Organ failure is highly associated with mortality59 and improvement in 
1704 
organ function is a key goal for critical care physicians. In the study by Marik et al.36, participants 
1705 
who received the 3-drug regimen had substantial improvements in the trajectory of organ failure 
1706 
over the first 72-hours of their ICU stay. If the combination of vitamin C, hydrocortisone, and vitamin 
1707 
B1 can improve organ function in the first 72-hours following ICU admission, we believe that 
1708 
clinicians will likely quickly adopt this safe and inexpensive therapy. Importantly, this outcome can 
1709 
be measured early in the hospital stay and is therefore less likely to be affected by other potential 
1710 
elements of hospital care that can affect more distal outcomes (e.g., mortality).  
1711 


 
 
1712 
Kidney Injury: Renal failure has been estimated to occur in 23% of participants with sepsis and 
1713 
over 50% of participants with septic shock.60 In studies of participants with septic shock, there is a 
1714 
step-wise increase in mortality with worsening acute kidney injury (AKI).61 In addition, many 
1715 
participants who experience renal injury during septic shock do not recover renal function prior to 
1716 
hospital discharge and may require long term dialysis. As both data from the study by Marik et. al.36 
1717 
and a separate study of vitamin B1 in septic shock38 have shown substantial improvements in renal 
1718 
outcomes, kidney failure is a natural secondary outcome and one that could change practice 
1719 
independently from other factors – in other words, many clinicians would likely provide this therapy if 
1720 
they knew that kidney function could be protected, since this organ is vital to long-term health. 
1721 
 
1722 
Mortality: Finally, we will measure 30-day mortality. We anticipate that the combination of vitamin 
1723 
C, hydrocortisone, and vitamin B1 will reduce mortality in this high-risk population.  
1724 
 
1725 
5.3 Additional Secondary Outcomes 
1726 
5.3.1 Additional secondary outcomes 
1727 
Additional secondary outcomes will include length of ICU stay, length of hospital stay, ventilator-free 
1728 
days over the first 7-days after enrollment, shock-free days over the first 7-days after enrollment, 
1729 
and the incidence of delirium on day #3 of the ICU stay (as assessed using the Confusion 
1730 
Assessment Method [CAM-ICU] system).62 Sites at which the CAM-ICU is performed daily as part of 
1731 
standard-of-care should assess whether delirium occurs on any day during the initial ICU stay. See 
1732 
Appendix #2.  
1733 
 
1734 
5.3.2 90-day follow-up for Quality of Life assessment 
1735 
Sites may choose to participate in a long-term outcomes substudy exploring the effects of ascorbic 
1736 
acid, hydrocortisone, and thiamine vs. placebo on quality of life following sepsis. If a site chooses to 
1737 
participate, a trained research assistant/investigator at the site (who is blinded to treatment arm) will 
1738 
contact all participants who were alive at 30-days, and perform the SF-36 at day 90 following 
1739 
enrollment. The SF-36 is a 36-Item Short-Form Health Survey (SF-36), a validated survey of 
1740 
general quality of life in adults, can be administered in person or over the telephone by research 
1741 
personnel. It measures eight different dimensions: physical functioning, bodily pain, role limitations 
1742 
due to physical health problems, role limitations due to personal or emotional problems, emotional 
1743 
well-being, social functioning, energy/fatigue, and general health perceptions, as well as one 
1744 
question asking about perceived changes in health. The telephone version of the 36-Item Short-
1745 
Form Health Survey has been validated63,64 and used in sepsis.65-68  
1746 
 
1747 
5.4 Safety 
1748 
5.4.1 Definitions  
1749 
The following definitions will be used69:  
1750 
 
1751 
Adverse event: any untoward medical occurrence in a participant to whom a medicinal product is 
1752 
administered and which does not necessarily have a causal relationship with this treatment 
1753 
 
1754 
Serious adverse event: any untoward medical occurrence that at any dose requires inparticipant 
1755 
hospitalization or prolongation of existing hospitalization, results in persistent or significant disability 
1756 
or incapacity, results in a congenital anomaly or birth defect, is life-threatening, or results in death 
1757 
 
1758 
Unexpected serious adverse event: a serious adverse reaction, the nature, severity or outcome of 
1759 
which is not consistent with the reference safety information 
1760 
 
1761 


 
5.4.2 Specific adverse event data collection 
1762 
To assess specific amd potentially serious adverse events that may be related to the combination of 
1763 
the study medications, we will collect data on the following:  
1764 
 
1765 
Serious Adverse Event 
Definition 
Hyperglycemia 
Serum glucose >300mg/dl in the first 120-hours after 
enrollment 
Hypernatremia 
Serum sodium (> 150 mmol/L) occurring in the first 120-
hours after enrollment 
New Infection 
As determined by the site principal investigator at each 
site. Should be a new organism or site of infection and 
believed to be unrelated to the initial presenting 
infectious source. Many will have the initiation of new 
antibiotics or a change in antibiotics. 
Catheter-site 
Lung 
Gastrointestinal 
Urinary tract 
Other 
Serious allergic reaction 
Anaphylaxis or other allergic reaction requiring systemic 
corticosteroids. Allergic reaction should be related (or 
suspected to be related) to the study medicaiton  
Renal calculus 
Development of a renal calculus between enrollment 
and 30-day follow-up (based on question asked during 
follow-up phone call). 
 
1766 
5.4.3 Adverse Event Reporting 
1767 
Any Unexpected Serious Adverse Events thought to be related to the study drug (as determined by 
1768 
the site investigator) will be reported to the  and all above listed Serious Adverse Events will be 
1769 
reported to the coordinating site, the data safety monitoring board (see below), and the regulatory 
1770 
authorities as applicable (i.e. IRB, FDA). Reporting of Serious Adverse Events will be done in 
1771 
aggegate after every 50 patients are enrolled. Unexpected Serious Adverse Event will additionally 
1772 
be reported to the coordinating site within 72-hours.  
1773 
 
1774 
5.4.5 Safety Monitoring Labs 
1775 
As detailed above, safety monitoring labs will be obtained at 120-hours, after completion of the 
1776 
study protocol.  
1777 
 
1778 
6. SAMPLE SIZE CALCULATION AND STATISTICAL ANALYSIS PLAN  
1779 
6.1 Sample size calculation 
1780 
The study has been powered to have at least 80% power for the primary outcome and all key 
1781 
secondary outcomes as follows:  
1782 
 
1783 
SOFA Score: Based on preliminary data36, we conservatively anticipate a decrease in SOFA score 
1784 
of 6 (standard deviation [SD]: 4) in the treatment group and 4 (SD: 2) in the placebo group. With 
1785 
these estimates, enrollment of 200 participants (100/arm) at an alpha of 0.05 and using a t-test 
1786 
with unequal variance, the trial will provide > 99% power to detect a statistical significant difference 
1787 
between groups.  
1788 
 
1789 
Kidney Injury: Based on preliminary data from our study of vitamin B1 in septic shock,38 we 
1790 
anticipate that 30% of participants in the treatment group and 55% in the placebo group will have 
1791 
renal failure which will result in a 94% power for this outcome. This calculation and following 
1792 
calculation were performed using the Fisher’s exact test. 
1793 
  
1794 
Mortality: Based on preliminary data37,70,71, we anticipate that the control group will have a mortality 
1795 
of 40%. We estimate a treatment effect of 50% (risk ratio: 0.50) resulting in a mortality of 20% in the 
1796 
treatment group. With these estimates, 182 participants will lead to 80% power. To further increase 
1797 
the trial’s power and due to potential loss-to-follow-up, we will aim to enroll 200 participants. These 
1798 


 
estimates are conservative compared to the Marik et al. study which found a treatment effect 
1799 
corresponding to a risk ratio of 0.21 which persisted in adjusted analysis.36  
1800 
 
1801 
6.2 Statistical analysis plan 
1802 
6.2.1 General considerations 
1803 
The statistical analyses and reporting will adhere to the CONSORT guidelines.72,73 All tests will be 
1804 
two-sided, a p-value < 0.05 will be considered significant, and all confidence intervals will have 95% 
1805 
coverage. All analyses will be conducted on a modified intention-to-treat basis only including 
1806 
participants receiving at least the first dose of the study medications. In a double-blind trial, this 
1807 
approach is unbiased while increasing precision.74 The two groups will be compared in relation to 
1808 
baseline characteristics using descriptive statistics.  
1809 
 
1810 
The persons conducting the statistical analysis will be blinded to the randomized allocation. Groups 
1811 
will be designated as “A” and “B” until all pre-specified analyses are performed and shared with all 
1812 
authors and the Data Safety Monitoring Board. 
1813 
 
1814 
6.2.2 SOFA score and renal failure 
1815 
The change in SOFA score will be calculated and compared between groups using the Wilcoxon 
1816 
Rank Sum test (if the change is not normally distributed) or by a t-test if the change is approximately 
1817 
normally distributed. Fisher’s exact tests will be used to compare the incidence of renal failure 
1818 
during the index ICU stay. 
1819 
  
1820 
If a participant expires prior to the 72-hour time point, SOFA scores will be imputed based on a pre-
1821 
defined plan as follows. If a participant expires before 24-hours has elapsed, a 20% increase from 
1822 
baseline will be imputed. If a participant expires between 24-hours and 48-hours, a 15% increase 
1823 
from the 24-hour time point will be imputed. If a participant dies between 48-hours and 72-hours, a 
1824 
20% increase from the 24-hour time point will be imputed. Sensitivity analyses will be performed 
1825 
using various other imputation techniques. Specifically, we will perform 1) a sensitivity analysis in 
1826 
which the worst possible SOFA score (score of 24) is imputed for those participants who expire, 2) a 
1827 
sentivity analysis in which the last SOFA score for participants who expire will be carried forward, 
1828 
and 3) a sensitivity analysis in which only those patients who survive to 72-hours are included. 
1829 
These sensitivity analyses were chosen to model ‘worst-possible’ and ‘best-possible’ scenarios. For 
1830 
the secondary outcome of renal failure, participants who expire during their ICU stay will be 
1831 
assessed to have developed renal failure if they demonstrated any degree of unresolved KDIGO 
1832 
acute kidney injury prior to death. If there was no evidence of acute kidney injury prior to death or if 
1833 
kidney injury had fully resolved, these participants will be assessed as not having developed renal 
1834 
failure.  
1835 
 
1836 
6.2.3 30-day mortality 
1837 
Survival until 30 days will be analyzed using survival analysis. Participants lost to follow-up will be 
1838 
censored and the censoring will be assumed non-informative. Results will be presented with 
1839 
Kaplan-Meier curves and the groups compared using the log-rank test.75 Hazard ratios with 95% 
1840 
confidence intervals will be obtained using Cox’s proportional hazards models.76 The proportional 
1841 
hazards assumption will be verified by visual inspection of the Kaplan-Meier curves and statistically 
1842 
by including a product term (i.e. “interaction”) between the treatment group variable and the natural 
1843 
logarithm of time in the model.77 If the proportional hazards assumption is not met, only the Kaplan-
1844 
Meier curves and the p-value from the log-rank test will be presented. 
1845 
 
1846 
Adverse events and other binary outcomes will be presented and analyzed like renal failure. 
1847 
 
1848 
6.2.4 Additional Secondary Analyses 
1849 
Both ICU and hospital length of stay will be compared using Wilcoxon Rank Sum tests. Ventilator 
1850 
and shock free days over the first 7-days after enrollment will likewise be compared using the 
1851 


 
Wilcoxon Rank Sum given that the data will likely be not normally distributed. In these latter two 
1852 
analyses, patients who expire prior to 7-days will be assessed to have 0 ventilator or shock free 
1853 
days if they had died while on a ventilator or vasopressor respectively. The incidence of delirium will 
1854 
be compared using the Fisher’s exact test. For the quality-of-life outcome (i.e. 90-day SF-36), the 
1855 
primary analysis will only include patients with available data. As a secondary analysis, multiple 
1856 
imputation will be used to estimate SF-36 scores in all patients not known to be dead at 90 -days. 
1857 
 
1858 
6.2.5 Subgroup analyses  
1859 
The analysis will include three pre-defined subgroup analyses for the primary and key secondary 
1860 
outcomes according to 1) participants with initially high SOFA scores (≥9). This cut-off was chosen 
1861 
to represent a population with a ≥50% predicted likelihood of mortality78 2) baseline vitamin B1 
1862 
deficiency and 3) baseline adrenal insufficiency. We will not plan to perform a subgroup analysis 
1863 
according to vitamin C deficiency, as prior work has shown that the vast majority of participants with 
1864 
septic shock have vitamin C levels below the reference range.36 Vitamin B1 deficiency will be 
1865 
defined as a plasma vitamin B1 level ≤ 7 nmol/L as has been previously described.37 Adrenal 
1866 
insufficiency will be defined as a cortisol level <10µg/dL.43 The trial is not powered to detect 
1867 
subgroup differences and these will be considered exploratory and hypothesis generating.    
1868 
 
1869 
6.2.6 Statistical stopping criteria  
1870 
Since the primary outcome is not mortality, there will be no formal stopping criteria for efficacy. 
1871 
There will be no predefined stopping criteria for futility since enrollment of the full cohort might allow 
1872 
for detection of efficacy in subgroups or in other outcomes even if the primary outcome is negative.  
1873 
 
1874 
7. DATA COLLECTION AND MANAGEMENT  
1875 
7.1 Data collection process  
1876 
Data collection will be the responsibility of the individual site investigators with oversite from the trial 
1877 
coordinating center. Most variables (i.e. demographics, sepsis characteristics and laboratory 
1878 
results) will be obtained prospectively from the electronic medical record. 30-day follow-up 
1879 
regarding safety and mortality end-points will be obtained via telephone call post-discharge (unless 
1880 
the participant remains in the hospital at 30-days). Data will be entered directly into the online 
1881 
database software (see below).  
1882 
 
1883 
7.2 Variables 
1884 
Will be provided on the online CRF. A PDF version is available upon request. 
1885 
 
1886 
7.3 Data quality and validity  
1887 
Data quality and validity will be optimized by using a detailed data dictionary which will be 
1888 
distributed to all sites. Data quality will be monitored both centrally by the coordinating site and 
1889 
locally by each site principal investigator.  
1890 
 
1891 
7.4 Data storage and security  
1892 
The database application we will use is REDCap Cloud (https://www.redcapcloud.com/). REDCap 
1893 
Cloud is a professional database that provides a user-friendly interface. The REDCap Cloud data 
1894 
management system is secure, fully compliant with all regulatory guidelines, and includes a 
1895 
complete audit-trail for data entry validation. Through these mechanisms, as well as relevant 
1896 
training for all involved parties, participant confidentiality will be safeguarded. All members of the 
1897 
research team will be required to complete standardized training in REDCap cloud, which will be 
1898 
documented within the software.  
1899 
 
1900 
The consent form and other trial documents for each participant will initially be stored in a secure, 
1901 
locked place at the individual sites. Participating sites will be responsible for maintaining their own 
1902 
trial documents and study materials (e.g. signed ICFs, site logs etc). Trial documents generated at 
1903 
the Coordinating Center will be maintained the Coordinating Center. Following completion of the 
1904 


 
trial, documents will be maintained for a period of at least 2-years at each site per FDA regulations 
1905 
(or longer depending on local IRB guidelines). 
1906 
 
1907 
8. ETHICAL CONSIDERATIONS  
1908 
8.1 Risks and Benefits  
1909 
8.1.1 Potential benefits 
1910 
Potential Benefits to Individual Participant: Assuming our hypothesis is correct and our results are 
1911 
comparable to those previously published36, individual participants enrolled in our study and 
1912 
randomized to the treatment arm will benefit from a better trajectory of organ failure and improved 
1913 
mortality. As many participants who survive an initial episode of sepsis will have a future admission for 
1914 
sepsis, participants participating in this study but randomized to the placebo arm may see a future 
1915 
benefit from knowledge gained. 
1916 
 
1917 
Potential Benefits to Society: Septic shock remains a highly morbid clinical condition for which there 
1918 
is no specific therapy. Our study, assuming our hypothesis is confirmed, will provide strong support for 
1919 
the widespread adoption of vitamin C, corticosteroids, and vitamin B1 for participants with septic 
1920 
shock. This, in turn, will significantly improve participant outcomes and reduce the global burden of 
1921 
death related to septic shock. Thus, even if participants are randomized to the placebo arm, their 
1922 
involvement with this study has tremendous potential benefits for society as whole. If vitamin C, 
1923 
corticosteroids, and vitamin B1 are found to be neutral or harmful (the latter being highly unlikely), 
1924 
society will benefit as the study will likely prevent the widespread dissemination of an ineffective 
1925 
medication combination.  
1926 
 
1927 
8.1.2 Potential harms  
1928 
Study Drug  
1929 
Vitamin C – Ascorbic acid is a water-soluble essential vitamin that is safe even at high doses. 
1930 
Nevertheless, adverse effects related to high-dose ascorbic acid have been described. These 
1931 
adverse effects include diarrhea/abdominal bloating, increased oxalate excretion, iron overload in 
1932 
participants with hemochromatosis, and hemolysis in participants with G6PD deficiency.79  We 
1933 
exclude participants with known renal failure (CKD ≥3b),  known G6PD deficiency, or known 
1934 
hemochromatosis to limit these potential risks. We will additionally exclude participants with known 
1935 
allergy to ascorbic acid. Ascorbic acid has additionally been used in at least 3 clinical trials in critically-
1936 
ill populations without major associated adverse effect.40-42 
1937 
 
1938 
Hydrocortisone – Hydrocortisone is a well-established medication for the treatment of refractory 
1939 
shock in sepsis. Some studies (e.g. CORTICUS) have found an increased incidence of secondary 
1940 
infection in participants with septic shock who receive steroids.46 This finding has not been 
1941 
replicated in other large trials of corticosteroids for sepsis.47 Additional hypothetical risks to the 
1942 
administration of hydrocortisone to participants with septic shock (e.g. increased gastro-intestinal 
1943 
bleeding, muscle weakness, and delirium) have not been found in clinical trials of corticosteroids in 
1944 
sepsis.46,47 Finally, hydrocortisone may increase the risk of hyperglycemia and hypernatremia.  
1945 
 
1946 
Hydrocortisone will not be tapered in this study as prior studies have shown benefit with 
1947 
corticosteroids in septic shock without a taper.80 In addition, a recent large trial of corticosteroids in 
1948 
septic shock (ADRENAL, NEJM 2018) randomized patients to 7-days of corticosteroids or placebo 
1949 
and did not include a taper. In that trial there was no reported difference in rates of recurrent shock. 
1950 
 
1951 
Vitamin B1 – The only potential serious side effect that has been reported from vitamin B1 
1952 
administration is an extremely rare anaphylactic reaction (1:250,000 cases) and this might not even 
1953 
be of issue with the current manufactured version of vitamin B1 in the United States. The risk of an 
1954 
anaphylactic reaction was associated with a vitamin complex dispensed in Europe, and whether 
1955 


 
vitamin B1 was the actual offending agent remains unknown; however, this 0.0004% theoretical 
1956 
chance of an adverse reaction is incredibly low. In a series of 989 participants in the United States 
1957 
who received intravenous vitamin B1, none had an anaphylactic reaction and the only reported side 
1958 
effects were minor consisting of transient local irritation or in one case pruritus (0.093%).81 Further 
1959 
safety data comes from the clinical use of intravenous vitamin B1 at our coordinating site.  At Beth 
1960 
Israel Deaconess Medical Center (BIDMC, coordinating center) vitamin B1 is provided liberally for 
1961 
participants with nutritional deficiency – for example, BIDMC has administered intravenous vitamin 
1962 
B1 in over 8,000 separate participant encounters from 2002 until present. Despite this heavy usage, 
1963 
no adverse reactions were reported in any of the 8,000 participant encounters.    
1964 
 
1965 
The combination of vitamin C, hydrocortisone and vitamin B1 – To date, the only study of the 
1966 
combination of vitamin C, hydrocortisone and vitamin B1 was the above referenced study by Marik 
1967 
et. al.  
1968 
 
1969 
All procedures will take place at the study site. All research procedures and monitoring will be 
1970 
conducted by experienced personnel, and participants will be in the ICU given critical illness. This 
1971 
permits closer observation and more detailed monitoring by clinicians familiar with the care of 
1972 
participants experiencing and resuscitated from septic shock. 
1973 
 
1974 
Blood Collection 
1975 
Most participants will have existing venous or arterial catheters in place and we will be able to collect 
1976 
blood from these ports, essentially eliminating the risks associated with blood collection. In the very 
1977 
rare case that a participant does not have an indwelling line, the risk of venipuncture is extremely 
1978 
low, and will not exceed the risk of clinical blood draws the participant will already be receiving. 
1979 
 
1980 
Loss of Confidentiality 
1981 
All measures will be taken to ensure that no confidential information is released. All participant 
1982 
information will be stored in a password protected database to which only study investigators will 
1983 
have access. Additionally, all hard copies of study data will be kept in a locked office accessible only 
1984 
to study investigators. Thus, the risk of loss of confidentiality is very low. 
1985 
 
1986 
9. MONITORING 
1987 
9.1 Institutional Review Board (IRB) 
1988 
The study will be reviewed and approved by the IRB at each participating site.  
1989 
 
1990 
9.2 Data Safety and Monitoring Board (DSMB) 
1991 
The DSMB will be responsible for safeguarding the interests of trial participants, assessing the 
1992 
safety and efficacy of the interventions during the trial, and for monitoring the overall conduct of the 
1993 
clinical trial. The DSMB will consist of three clinicians with critical care experience in the 
1994 
management of septic participants. An independent biostatistician/epidemiologist will prepare all 
1995 
DSMB reports. The DSMB members will be chosen such to avoid any financial or intellectual 
1996 
conflicts of interest. The DSMB will review deidentified data after every 50 participants are enrolled 
1997 
to assess for safety; unless there are group differences necessitating unblinding (as determined by 
1998 
the DSMB), the DSMB will be blinded to treatment groups. The trial will continue while the DSMB 
1999 
review data. After each review, the DSMB will create a short report to the steering committee with 
2000 
recommendations for continuation, modifications, or termination of the trial. Criteria for 
2001 
recommending termination will be at the discretion of the DSMB and there will be no formal 
2002 
statistical criteria for termination due to efficacy or safety. A detailed charter for the DSMB will be 
2003 
provided.  
2004 
 
2005 
DSMB Members 
2006 


 
Clifton Callaway, MD, PhD [DSMB Chair] 
2007 
University of Pittsburgh 
2008 
400A Iroquois 
2009 
Pittsburgh, PA 15260 
2010 
(412) 647-8287 
2011 
callawaycw@upmc.edu 
2012 
Professor (tenured) of Emergency Medicine; Executive Vice-Chair of Emergency Medicine; UPMC 
2013 
Professor of Emergency Medicine Research 
2014 
Expertise: Cardiac Arrest/Clinical Trials  
2015 
 
2016 
Taylor Thompson, MD  
2017 
Massachusetts General Hospital 
2018 
55 Fruit Street 
2019 
Boston, MA 02114 
2020 
(617) 724-7823 
2021 
tthompson1@partners.org 
2022 
Professor of Medicine, Harvard Medical School 
2023 
Director, Critical Care Translational Research, Pulmonary/Critical Care Unit, MGH 
2024 
Medical Director, ARDS Network Clinical Coordinating Center  
2025 
Expertise:  Sepsis/Clinical Trials 
2026 
 
2027 
Shahzad Shaefi, MD MPH  
2028 
Beth Israel Deaconess Medical Center 
2029 
One Deaconess Raod 
2030 
Boston, MA 02115 
2031 
(617) 355-6286 
2032 
sshaefi@bidmc.harvard.edu 
2033 
Attending Physician, Department of Anesthesia, Critical Care and Pain 
2034 
Expertise:  Critical Care Medicine 
2035 
 
2036 
Manya Harsch, MS 
2037 
Principal Statistician, Technomics Research, LLC 
2038 
 (763) 473-6374 
2039 
mharsch@technomicsresearch.com  
2040 
Expertise: Biostatistics 
2041 
 
2042 
10 CLINICAL MONITORING PLAN 
2043 
The detailed clinical monitoring plan has been developed and is available from the Coordianting 
2044 
Center upon request. 
2045 


 
11. TIMELINE AND ENROLLMENT  
2046 
11.1 Timeline  
2047 
 
Pre-trial 
Months 0-5 
Months 6-11 
Months 12-18 
Funding 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol development and 
modifications 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FDA IND approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethical approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Registration with 
Clinicaltrials.gov 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Creation of data dictionary  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Creation of randomization 
list 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Site start-up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Education of site 
personnel  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DSMB monitoring 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrollment and 
assessment of outcomes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cleaning and closing of 
the database 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unblinding & Data analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Main manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Publication and 
presentation of results 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2048 
11.2 Screening & Enrollment  
2049 
Enrollment at each site will be continuously monitored by the site investigator and the principal 
2050 
investigator. Each site will be expected to maintain a screening log including all participants who 
2051 
meet all eligibility criteria at that site. A standardized screening log will be provided to each site via 
2052 
RedCap Cloud—thus allowing for continuous updating of the screening log and will allow capture of 
2053 
all screening failures.    
2054 
 
2055 


 
Enrollment will be competitive (i.e. without specific enrollment caps). Number of enrollments at each 
2056 
site will be shared with all sites on a monthly basis. Sites will be expected to complete all elements 
2057 
of the online CRF within 48-hours of each time point. In the case that a site continuously 
2058 
underperforms despite troubleshooting and feedback, the steering committee will evaluate whether 
2059 
enrollment will continue at that site. 
2060 
 
2061 
12. FUNDING 
2062 
Funding for the present trial is provided by the Good Ventures Foundation 
2063 
(http://www.goodventures.org/). The funding agency will have no role in the design and conduct of 
2064 
the study, collection, management, analysis, and interpretation of the data, preparation, review, or 
2065 
approval of the manuscript, or the decision to submit the manuscript for publication.  
2066 
 
2067 
13. PUBLICATION 
2068 
The manuscript will adhere to the CONSORT guidelines.72,73 The principal investigator will be 
2069 
responsible for assigning authorship position and will follow authorship guidelines from the 
2070 
International Committee of Medical Journal Editors.82 At a minimum, all members of the Steering 
2071 
Committee and all site Principal Investigators (for sites enrolling at least 10 participants) will be 
2072 
included in the primary author list. The main results will be presented at an international conference. 
2073 
The trial results will be shared with participating sites and via press releases but not directly with the 
2074 
participants. 
2075 
 
2076 
14. DATA SHARING 
2077 
Six months after the publication of the last results, all de-identified individual participant data will be 
2078 
made available for data sharing.83 Procedures, including re-coding of key variables, will be put in 
2079 
place to allow for complete de-identification of the data. All relevant trial-related documents, 
2080 
including the protocol, data dictionary, and the main statistical code, will be shared along with the 
2081 
data. There will be no predetermined end date for the data sharing. Data will be available for any 
2082 
research purpose to all interested parties who have approval from an independent ethics review 
2083 
committee and who have a methodological sound proposal as determined by the steering 
2084 
committee of the current trial. Interested parties will be able to request the data by contacting the 
2085 
principal investigator. Authorship of publications emerging from the shared data will follow standard 
2086 
authorship guidelines from the International Committee of Medical Journal Editors82 and might or 
2087 
might not include authors from the steering committee depending on the nature of their involvement.  
2088 
 
2089 
15. TASKS AND RESPONSIBILITIES  
2090 
Principal investigator and sponsor: Overall responsibility for protocol development, funding, budget 
2091 
overview, data dictionary development, ethical approval, trial registration, daily management, trial 
2092 
oversight and collection of adverse events, contact to the pharmacy, contact to Good Clinical 
2093 
Practice monitoring unit and the data and safety monitoring board, assessment of overall 
2094 
recruitments, potential recruitment of additional sites, data analysis, and dissemination and 
2095 
presentation of results.  
2096 
 
2097 
Steering committee: Protocol development, funding, budget overview, data dictionary development, 
2098 
trial oversight, dissemination of results, responsibilities as principal investigator for short time 
2099 
periods.  
2100 
 
2101 
Site investigators: Responsible for site-specific enrollment, evaluation of eligible patients not 
2102 
included, education of personnel at participating sites, reporting of site-specific issues or challenges 
2103 
to the principal investigator, participant consent for data collection, collecting and reporting data 
2104 
regarding adverse drug events. 
2105 
 
2106 
Clinical team: Administration of the study drug, participant consent for data collection.  
2107 


 
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2108 
1. 
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2109 
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Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for 
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Management of Sepsis and Septic Shock: 2016. Critical care medicine. 2017;45(3):486-552. 
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Flannery AH, Bastin MLT, Magee CA, Bensadoun ES. Vitamin C in Sepsis: When It Seems Too Sweet, It 
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Might (Literally) Be. Chest. 2017;152(2):450-451. 
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57. 
Pandharipande PP, Shintani AK, Hagerman HE, et al. Derivation and validation of Spo2/Fio2 ratio to 
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impute for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment 
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score. Critical care medicine. 2009;37(4):1317-1321. 
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outcomes in acute kidney injury. Critical care (London, England). 2007;11(2):R31. 
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de Grooth HJ, Geenen IL, Girbes AR, Vincent JL, Parienti JJ, Oudemans-van Straaten HM. SOFA and 
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mortality endpoints in randomized controlled trials: a systematic review and meta-regression 
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Schrier RW, Wang W. Acute renal failure and sepsis. The New England journal of medicine. 
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Kidney Injury in Patients with Septic Shock. American journal of respiratory and critical care 
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medicine. 2016;193(3):281-287. 
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Schmidt K, Worrack S, Von Korff M, et al. Effect of a Primary Care Management Intervention on 
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Mental Health-Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. Jama. 
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Zhang K, Mao X, Fang Q, et al. Impaired long-term quality of life in survivors of severe sepsis : 
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Wittbrodt P, Haase N, Butowska D, et al. Quality of life and pruritus in patients with severe sepsis 
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Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine 
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Rhee C, Dantes R, Epstein L, et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs 
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Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for 
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Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explanation and elaboration: updated 
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Fergusson D, Aaron SD, Guyatt G, Hebert P. Post-randomisation exclusions: the intention to treat 
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Communications in Statistics - Theory and Methods. 1984;13(20):2469–2486. 
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Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ 
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medicine. 1998;26(11):1793-1800. 
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79. 
Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C 
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Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and 
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fludrocortisone on mortality in patients with septic shock. Jama. 2002;288(7):862-871. 
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Wrenn KD, Murphy F, Slovis CM. A toxicity study of parenteral thiamine hydrochloride. Annals of 
2308 
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Taichman DB, Sahni P, Pinborg A, et al. Data Sharing Statements for Clinical Trials - A Requirement of 
2313 
the International Committee of Medical Journal Editors. N Engl J Med. 2017;376(23):2277-2279. 
2314 


 
Appendices 
2315 
 
2316 
Appendix 1: Abbreviations 
2317 
ICH………………..International Conference on Harmonization 
2318 
SPIRIT………………..Standard Protocol Items: Recommendations for Interventional Trials  
2319 
ACT………………..Ascorbic Acid, Corticosteroids, and Thiamine  
2320 
CKD………………..Chronic Kidney Disease  
2321 
SOFA………………..Sequential Organ Failure Assessment 
2322 
IND………………..Investigational New Drug 
2323 
FDA………………..Food and Drug Administration 
2324 
ICU………………..Intensive Care Unit 
2325 
SaO2………………..Oxygen Saturation 
2326 
FiO2………………..Fraction of Inspired Oxygen 
2327 
GCS………………..Glasgow Coma Scale 
2328 
UOP………………..Urine Output 
2329 
RRT………………..Renal Replacement Therapy 
2330 
CAM………………..Confusion Assessment Method 
2331 
NCHS……………….. National Center for Health Statistics 
2332 
NDI………………..National Death Index 
2333 
AKI………………..Acute Kidney Injury 
2334 
SD……………….. tandard deviation 
2335 
CRF………………..Case Report Form 
2336 
BIDMC………………..Beth Israel Deaconess Medical Center (Coordinating Center) 
2337 
IRB………………..Institutional Review Board 
2338 
DSMB………………..Data Safety and Monitoring Board 
2339 
 
2340 
 
2341 
 
2342 
 
2343 
 
2344 
 
2345 
 
2346 
 
2347 
 
2348 
 
2349 
 
2350 
 
2351 
 
2352 
 
2353 
 
2354 
 
2355 
 
2356 
 
2357 
 
2358 
 
2359 
 
2360 
 
2361 
 
2362 


 
Appendix 2: CAM-ICU Form 
2363 
 
2364 
 
2365 
 
2366 


 
3. SUMMARY OF PROTOCOL CHANGES 
2367 
 
2368 
v2.1 – Original trial protocol. v1.0 of the protocol was a draft protocol that was updated following the 
2369 
initial investigator meeting.  
2370 
v2.2 – Added external study sites. Modifications to protocol at coordinating center (reflected in v2.3 
2371 
for all sites).   
2372 
v2.3 – Change in exclusion criteria from CKD ≥3b [GFR < 45ml/hr]) to receiving renal replacement 
2373 
therapy. Clarification that sepsis should be the likely cause of hypotension resulting in vasopressor 
2374 
requirement and that consent/enrollment should be within 24-hours of meeting inclusion criteria. 
2375 
Change in contingency should open label thiamine be prescribed by the clinical tram. Allowance for 
2376 
a consideration of sample size adjustment should the SOFA score and/or mortality for the full study 
2377 
cohort (examined without consideration of study group) fall below that anticipated in the power 
2378 
analysis. Clarification of adverse event reporting procedures.  
2379 
v2.4 – Addition of study site. Correction of oversight in exclusion criteria with respect to clinical 
2380 
ascorbic acid supplementation. Clarification of SOFA scale to assign a renal SOFA score of 4 if a 
2381 
patient is started on renal replacement therapy.  
2382 
 
2383 

Prot_001.pdf: 
 
Vitamin C, Hydrocortisone, and Vitamin B1 in Sepsis – version 2.3 
Page 1 of 34 
 
Ascorbic Acid, Hydrocortisone, and Thiamine in Sepsis and Septic Shock 
– A Randomized, Double-Blind, Placebo-Controlled Trial 
 
Acronym: Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) Trial 
 
CLINICAL TRIAL PROTOCOL 
 
             Version 2.4 
December 13, 2018 
            IND: 136882 
 
 
Clinical Trials.Gov Identifier: NCT03389555 
 
Principal investigator: 
Michael W. Donnino, MD 
Director of Center for Resuscitation Science 
Associate Professor of Medicine, Harvard Medical School 
Attending Physician in Emergency and Critical Care Medicine, BIDMC 
 
Beth Israel Deaconess Medical Center 
West Clinical Campus 2nd Floor 
One Deaconess Road, Boston MA 02215 
Phone: 617-754-2295 
Fax: 617-754-2350 
Email: mdonnino@bidmc.harvard.edu 
 
Funded By: 
Open Philanthropy Project (https://www.openphilanthropy.org/) 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Vitamin C, Hydrocortisone, and Vitamin B1 in Sepsis – version 2.3 
Page 2 of 34 
 
SYNOPSIS .........................................................................................................................................................5 
TRIAL OVERVIEW ............................................................................................................................................6 
STEERING COMMITTEE ................................................................................................................................7 
TRIAL SITES ......................................................................................................................................................8 
1. BACKGROUND AND SIGNIFICANCE ......................................................................................................9 
1.1 Scope of the Problem .............................................................................................................................9 
1.2 Existing Interventions .............................................................................................................................9 
1.3 The combination of vitamin C, hydrocortisone, and vitamin B1 may improve outcomes ............9 
1.4 Physiologic Rationale .............................................................................................................................9 
2. TRIAL DESIGN ........................................................................................................................................... 10 
2.1 Overview ................................................................................................................................................ 10 
2.2 Allocation ............................................................................................................................................... 10 
2.3 Intervention ........................................................................................................................................... 10 
2.3.1 Vitamin C, Hydrocortisone, and Vitamin B1 ............................................................................. 10 
2.3.2 Placebo........................................................................................................................................... 10 
2.4 Blinding .................................................................................................................................................. 10 
2.5 
Regulatory Issues ........................................................................................................................... 10 
3.  SETTING AND PARTICIPANT POPULATION .................................................................................... 11 
3.1 Setting .................................................................................................................................................... 11 
3.2 Inclusion criteria ................................................................................................................................... 11 
3.3 Exclusion criteria .................................................................................................................................. 11 
3.4 Pregnancy ............................................................................................................................................. 11 
4. TRIAL PROCEDURES .............................................................................................................................. 12 
4.1 Participant Identification ...................................................................................................................... 12 
4.2 Consent procedures ............................................................................................................................ 12 
4.3 Randomization ...................................................................................................................................... 12 
4.4 Drug preparation and administration ................................................................................................. 13 
4.4.1 Contingencies and Participant Withdrawal ............................................................................... 13 
4.5 Specimen collection procedures ........................................................................................................ 13 
4.5.1 Timing and volume of blood draw .............................................................................................. 13 
4.5.2 Specimen samples ....................................................................................................................... 13 
4.5.3 Biomarker tube initial processing and shipping ........................................................................ 14 
4.6 Study flow diagram .............................................................................................................................. 14 


 
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4.7 General Sepsis Management ............................................................................................................. 14 
4.8 Glucometer use during the study period .......................................................................................... 15 
5. OUTCOMES ............................................................................................................................................... 15 
5.1 Definitions .............................................................................................................................................. 15 
5.1.1 Primary Outcome .......................................................................................................................... 15 
5.1.2 Key Secondary Outcomes ........................................................................................................... 15 
5.2 Rationale for Outcomes ...................................................................................................................... 16 
5.3 Additional Secondary Outcomes ....................................................................................................... 16 
5.3.1 Additional secondary outcomes .................................................................................................. 16 
5.3.2 90-day follow-up for Quality of Life assessment ...................................................................... 17 
5.4 Safety ..................................................................................................................................................... 17 
5.4.1 Definitions ...................................................................................................................................... 17 
5.4.2 Specific adverse event data collection ...................................................................................... 17 
5.4.3 Adverse Event Reporting ............................................................................................................. 18 
5.4.5 Safety Monitoring Labs ................................................................................................................ 18 
6. SAMPLE SIZE CALCULATION AND STATISTICAL ANALYSIS PLAN ........................................... 18 
6.1 Sample size calculation ....................................................................................................................... 18 
6.2 Statistical analysis plan ....................................................................................................................... 19 
6.2.1 General considerations ................................................................................................................ 19 
6.2.2 SOFA score and renal failure ...................................................................................................... 19 
6.2.3 30-day mortality ............................................................................................................................. 20 
6.2.5 Subgroup analyses ....................................................................................................................... 20 
6.2.6 Statistical stopping criteria ........................................................................................................... 20 
7. DATA COLLECTION AND MANAGEMENT .......................................................................................... 20 
7.1 Data collection process ....................................................................................................................... 20 
7.2 Variables ................................................................................................................................................ 20 
7.3 Data quality and validity ...................................................................................................................... 21 
7.4 Data storage and security ................................................................................................................... 21 
8. ETHICAL CONSIDERATIONS ................................................................................................................. 21 
8.1 Risks and Benefits ............................................................................................................................... 21 
8.1.1 Potential benefits .......................................................................................................................... 21 
8.1.2 Potential harms ............................................................................................................................. 21 
9. MONITORING............................................................................................................................................. 23 
9.1 Institutional Review Board (IRB) ........................................................................................................ 23 


 
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9.2 Data Safety and Monitoring Board (DSMB) ..................................................................................... 23 
10 CLINICAL MONITORING PLAN ............................................................................................................. 24 
11. TIMELINE AND ENROLLMENT ............................................................................................................ 25 
11.1 Timeline ............................................................................................................................................... 25 
11.2 Screening & Enrollment .................................................................................................................... 25 
12. FUNDING .................................................................................................................................................. 26 
13. PUBLICATION .......................................................................................................................................... 26 
14. DATA SHARING ...................................................................................................................................... 26 
15. TASKS AND RESPONSIBILITIES ........................................................................................................ 26 
References ...................................................................................................................................................... 28 
Appendices ...................................................................................................................................................... 33 
Appendix 1: Abbreviations ......................................................................................................................... 33 
Appendix 2: CAM-ICU Form ..................................................................................................................... 34 
 


 
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SYNOPSIS 
 
The “Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis (ACTS)” trial is a multi-center, double-
blind, randomized clinical trial that aims to determine the impact of Vitamin C, Hydrocortisone, and 
Vitamin B1 vs. Placebo on organ injury and mortality on participants with sepsis and septic shock. 
The trial will be conducted in accordance with all applicable national and international laws, 
regulations, and guidelines The trial and this protocol is developed in accordance with the 
International Conference on Harmonization (ICH) guidelines1-3 and the Standard Protocol Items: 
Recommendations for Interventional Trials (SPIRIT) statement4,5. The principal investigator wrote 
the protocol with input from the steering committee. Any substantial changes or amendments to the 
protocol will be clearly documented and communicated to all relevant parties.  
 


 
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TRIAL OVERVIEW 
 
Title 
Vitamin C, Hydrocortisone, and Vitamin B1 in Sepsis and 
Septic Shock – A Randomized, Double-Blind, Placebo-
Controlled Trial (The ACTS Trial) 
Clinical Trials Number 
NCT03389555 
Sources of monetary or 
material support 
Open Philanthropy Project 
(https://www.openphilanthropy.org/)  
Study Sites 
12-sites in the United States 
Condition studied 
Sepsis and septic shock 
Interventions 
Vitamin C (1.5g every 6 hours x 4-days), hydrocortisone 
(50mg every 6 hours x 4-days), and Vitamin B1 (100mg 
every 6 hours x 4-days) 
Comparator  
Placebo  
Inclusion criteria 
• Adult participant (age ≥ 18 years) 
• Suspected (cultures drawn and antibiotic given) or 
confirmed (via culture results) infection 
• Receiving vasopressor (norepinephrine, 
phenylephrine, epinephrine, dopamine, vasopressin, or 
angiotensin II)  
Exclusion criteria 
• Member of a protected population (pregnant, prisoner) 
• Known history of kidney stones within the past 1 year 
• End stage renal disease (ESRD) requiring dialysis 
• Known history of G6PD deficiency 
• Known history of Hemochromatosis 
• Comfort Measures Only status 
• Anticipated death within 24-hours despite maximal 
therapy (as determined by the enrolling physician) 
• Receiving supplemental vitamin B1 in a dose greater 
than that contained in a multivitamin (<2mg) 
• Clinical indication for steroids (e.g. chronic use) as 
determined by the clinical team providing this drug 
• Clinical indication for ascorbic acid supplementation in 
any form  
• Clinical indication for vitamin B1 as determined by the 
clinical team providing this drug 
• Known allergy to vitamin C, hydrocortisone, or vitamin B1 
Study type 
Interventional 
Allocation: Randomized (1:1) 
Intervention model: Parallel group 
Masking: Double-blind 
Target sample size 
200 Participants (100/arm) 
Primary outcome 
Change in the Sequential Organ Failure Assessment 
(SOFA) score between enrollment and 72-hours 
Key secondary outcomes 
Incidence of renal failure during index ICU stay 
30-day mortality 


 
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STEERING COMMITTEE 
 
Michael Donnino, M.D.  
Associate Professor of Medicine 
Director, Center for Resuscitation Science  
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Paul E. Marik, M.D. 
Professor of Medicine 
Chief, Division of Pulmonary and Critical 
Care Medicine 
Eastern Virginia Medical School 
Ari Moskowitz, M.D. 
Attending, Pulmonary and Critical Care Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Katherine Berg, M.D. 
Assistant Professor of Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Lars W. Andersen, M.D., MPH, Ph.D 
Associate Professor of Medicine 
Research Center for Emergency Medicine 
Department of Clinical Medicine 
Aarhus University and Aarhus University Hospital 
Anne Grossestreuer, Ph.D. 
Instructor in Emergency Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Michael N. Cocchi, MD 
Assistant Professor of Emergency Medicine 
Beth Israel Deaconess Medical Center 
Harvard Medical School  
Joseph Miller, MD 
Attending, Emergency Medicine 
Department of Emergency Medicine 
Henry Ford Hospital 
Conflicts of interest 
The members of the steering committee have no financial conflicts of interest related to the current 
trial.  


 
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TRIAL SITES 
 
Coordinating Center 
Beth Israel Deaconess Medical Center 
330 Brookline Avenue 
Boston, MA 02215 
Site Investigator: Michael W. Donnino, MD 
 
Enrolling Sites* 
 
Hospital Name 
Location 
Site Principal Investigator 
Henry Ford Hospital 
Detroit, MI 
Bruno DiGiovine, MD 
DMC-Detroit Receiving Hospital 
Detroit, MI 
Rob Sherwin, MD 
DMC-Sinai-Grace Hospital 
Detroit, MI 
Rob Sherwin, MD 
Harper Hospital 
Detroit, MI 
Rob Sherwin, MD 
UT Health, The University of Texas 
Health Science Center 
Houston, TX 
Pratik Doshi, MD 
Mayo Clinic 
Phoenix, AZ 
Ayan Sen, MD 
Beth Israel Deaconess Medical 
Center 
Boston, MA 
Ari Moskowitz, MD 
Beaumont Hospital 
Royal Oak, MI 
Ron Otero, MD 
Brigham and Women’s Hospital 
Boston, MA 
Peter Hou, MD 
Long Island Jewish Hospital Center 
- Queens 
New York, NY 
Maksim Korotun, MD; Jonathan 
Gong, MD 
Long Island Jewish Hospital Center 
– Hyde Park 
New York, NY 
Ayelet Hilewitz, MD; Jonathan 
Gong, MD 
Mount Auburn Hospital 
Cambridge, MA 
Jessica McCannon, MD 
University of Pittsburgh 
Pittsburgh, PA 
David Huang, MD 
South Shore Hospital 
Weymouth, MA 
Mark Hershey, MD 
*Depending on study progress, sites may be added or removed in the future. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Vitamin C, Hydrocortisone, and Vitamin B1 in Sepsis – version 2.3 
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1. BACKGROUND AND SIGNIFICANCE 
1.1 Scope of the Problem  
The worldwide incidence of sepsis has been estimated at more than 23 million cases6 and sepsis 
contributes to more than a third of all hospital deaths in the United States.7,8 Mortality for those in 
septic shock with elevated lactate is more than 40%.9 In addition to high short-term mortality, sepsis 
is associated with significant post-discharge morbidity and mortality.10-15 The economic burden for 
participants suffering from sepsis is staggering with an estimated yearly financial burden of $17 
billion.16 Treatments are generally limited to antibiotics and intravenous fluids while providing support 
to maintain organ function.17,18  
 
1.2 Existing Interventions 
To date, numerous interventions have been tested for participants with sepsis and septic shock with 
limited, if any, success.19-22 Recently, three large studies found no benefit from early goal directed 
therapy over usual care in emergency department participants with sepsis.23-25 Other recent studies 
focusing on hemodynamics, fluid therapy, and transfusions have also failed to show a significant 
benefit in this participant population.26-28 Previous studies focusing on immunomodulary therapies or 
drotrecogin alfa have likewise shown disappointing results.29-35  
 
1.3 The combination of vitamin C, hydrocortisone, and vitamin B1 may improve outcomes  
In a before-and-after study exploring the effects of the combination of vitamin C, hydrocortisone, and 
vitamin B1 in a cohort of participants with sepsis and septic shock, Marik et. al. found a remarkable 
improvement in time to shock reversal (18.3 ± 9.8 hours vs. 54.9 ± 28.4 hours), organ injury (ΔSOFA 
4.8 ± 2.4 vs. 0.9 ± 2.7), and mortality (8.5% vs. 40.4%) following implementation of the drug ‘cocktail’ 
as compared to before implementation even after adjusting for potential confounders.36 This study 
joins other promising trials of individual elements of this drug combination. In a trial of vitamin B1 in 
septic shock, there was a substantial reduction in mortality and organ injury (particularly kidney 
injury) in those with vitamin B1 deficiency and septic shock who were given vitamin B1 as compared 
to placebo.37,38 In addition, several studies of vitamin C alone have shown promise in critically ill 
populations39-42 and a recent meta-analysis of corticosteroids in sepsis suggests potential benefit.43 
 
1.4 Physiologic Rationale 
The combination of vitamin C, hydrocortisone, and vitamin B1 is hypothesized to improve outcomes 
in sepsis through a number of mechanisms.36 Vitamin C is an important contributor to endothelial 
integrity and severe deficiency states (e.g. scurvy) can result in endothelial breakdown with resultant 
vascular leak and edema.44,45  In addition, vitamin C is a potent anti-oxidant and is integral to 
endogenous vasopressor synthesis.36 Hydrocortisone, a potential adjunctive therapy in septic 
shock46,47, may act synergistically with vitamin C.48,49 Vitamin B1, a key cofactor of pyruvate 
dehydrogenase, is a critical component of metabolic dysfunction without which a shift towards 
anaerobic energy production occurs.50 Vitamin B1 is also a necessary component of the pentose 
phosphate pathway, which plays a role in reducing oxidative stress.51,52 While the physiologic effects 
of these drugs given in combination is not entirely known, we hypothesize that there will be 
synergistic effects with respect the metabolic resuscitation of sepsis.  


 
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2. TRIAL DESIGN 
2.1 Overview 
This will be an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, 
double-blind, superiority trial of vitamin C, hydrocortisone, and vitamin B1 vs. placebo in participants 
with sepsis and septic shock. A total of 200 adult participants will be enrolled. The primary outcome 
will be the change in SOFA score between enrollment and 72-hours. Key secondary outcomes 
include the incidence of renal failure during the index ICU stay and survival at 30 days. 
 
2.2 Allocation 
Participants will be randomized in a 1:1 ratio to either the combination of vitamin C, hydrocortisone, 
and vitamin B1 or placebo in blocks with random sizes of 2 or 4. The randomization will be stratified 
according to site.53 An independent statistician will create the randomization list using a random 
number generator. The complete list will only be shared with an independent pharmacy consultant, 
who will not be involved in clinical care. The pharmacy consultant and the independent statistician 
will both store the randomization list. The research pharmacy at each enrolling site will receive a 
site-specific randomization list.   
 
2.3 Intervention 
2.3.1 Vitamin C, Hydrocortisone, and Vitamin B1 
The study drugs will consist of vitamin C (1.5g every 6 hours x 4-days), hydrocortisone (50mg every 6 
hours x 4-days), and vitamin B1 (100mg every 6 hours x 4-days). 
 
2.3.2 Placebo  
The placebo will consist of matching volumes of normal saline (0.9% NaCl). See below section 4.4 
for specifics of drug and placebo preparation.  
 
2.4 Blinding  
The trial will be double-blind; participants, investigators, and the clinical team will be blinded to the 
allocation. Only the pharmacy providing the study drug will be aware of the allocation. The 
pharmacy will not be involved with clinical care or outcome evaluation.  
 
As vitamin C possess a yellow tinge, the bags containing the vitamin C/placebo will be covered with 
light-protective bags. In testing, after dilution there is not distinguishing characteristics of the vitamin 
C vs. placebo in the IV tubing. Vitamin C, hydrocortisone, and vitamin B1 are not known to have 
distinctive rapid effects which could lead to unblinding.  
 
 
The decision to unblind will be at the complete discretion of the treating physician and clinical team. 
If a clinical team wishes to unblind a participant (e.g. if anaphylaxis occurs), they will contact the 
research pharmacy who will reveal the study group to the clinical team (but the research team will 
remain blinded). However, we do not expect many scenarios where emergency unblinding will be 
necessary. In case unblinding occurs, the reason(s) will be clearly documented in the case report 
form. The patient will no longer receive study medications, but will be followed for outcomes.  
 
2.5 Regulatory Issues 
An Investigational New Drug (IND) application was submitted to and approved by the Food and 
Drug Administration (FDA) for the study of vitamin C, hydrocortisone, and vitamin B1 in sepsis and 
septic shock (IND # 136882). 
 
The trial has been registered on ClinicalTrials.gov: NCT03389555 
 
 


 
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3.  SETTING AND PARTICIPANT POPULATION 
3.1 Setting 
The trial will be conducted at approximately 13 hospitals in the United States. Additional sites might 
be recruited if needed.  
 
3.2 Inclusion criteria 
Inclusion criteria:  
1) Adult participant (age ≥ 18 years) 
2) Suspected (cultures drawn and antibiotic given) or confirmed (via culture results) infection 
3) Receiving (continuous infusion) vasopressor (norepinephrine, phenylephrine, epinephrine, 
dopamine, angiotensin II, or vasopressin) 
a. Hypotension related primarily to sepsis as opposed to another cause of hypotension 
(e.g. bleed, cardiogenic shock) 
 
3.3 Exclusion criteria  
Exclusion criteria: 
1) Member of a protected population (pregnant, prisoner) 
2) Known history of kidney stones within the past 1 year (not including incidentally noted stones 
noted on imaging studies) 
3) End stage renal disease requiring dialysis (hemodialysis or peritoneal dialysis) 
4) Known history of G6PD deficiency 
5) Known history of Hemochromatosis 
6) Comfort Measures Only status 
7) Anticipated death within 24-hours despite maximal therapy (as determined by the enrolling 
physician)  
8) Receiving supplemental vitamin B1 in a dose greater than that contained in a multivitamin 
(<2mg) 
9) Clinical indication for steroids (e.g. chronic use) as determined by the clinical team providing this 
drug 
10) Clinical indication for ascorbic acid supplementation in any form  
11) Clinical indication for vitamin B1 as determined by the clinical team providing this drug 
12) Known allergy to vitamin C, hydrocortisone, or vitamin B1 
 
Justification of Inclusion and Exclusion Criteria: The inclusion criteria were chosen to isolate a septic 
participant population with high risk of organ injury and death. The exclusion criteria were chosen to 
minimize the risk of potential harm and to ensure that participants enrolled do not already have 
chronic end-stage renal failure with a high likelihood of early need for renal replacement therapy. By 
evaluating this high-risk population (i.e., most likely to die), we will target those most likely to benefit 
and therefore increase the probability of showing efficacy.19  
 
3.4 Pregnancy 
Hydrocortisone is considered pregnancy class C on the basis of animal studies showing an 
association between prenatal parenteral hydrocortisone use and risk of cleft-palate. In addition, 
there are concerns about effects of hydrocortisone on fetal growth and the possibility of neonatal 
adrenal insufficiency. The effects of high-dose vitamin C and thiamine in pregnancy are not entirely 
known. As such, participants who are pregnant will be excluded from the study. Prior to enrollment, 
all participants of potentially child-bearing potential (women aged <45 years54) will be required to 
have a negative serum or urine HCG test (generally performed as standard-of-care).  
 


 
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We will additionally inform all women of child-bearing potential who are randomized in this study 
that we recommend they remain abstinent or use two forms of birth control during the study period 
and for a period of 48-hours after the last dose of study drug.  
 
4. TRIAL PROCEDURES 
4.1 Participant Identification  
Screening will be performed in the emergency department and intensive care units (ICUs) with the 
assistance of electronic screening mechanisms . Detailed screening logs, with reason(s) for exclusion 
will be kept at each site and reported in the final publication.  
 
We anticipate that all patients, as part of standard-of-care for the septic patient, will have a urine or 
serum HCG test performed (if a female of child-bearing age). If this test is not sent as part of standard-
of-care, it should be sent prior to consent.   
 
4.2 Consent procedures 
Informed, written consent will be obtained for all participants prior to enrollment.  
 
After it is determined that they meet all inclusion criteria and no exclusion criteria, the participant (or 
legally authorized representative [LAR] if the participant is not able to provide consent) will be 
approached for written informed consent by a physician co-investigator from the team. The 
investigator will provide the participant/representative information regarding the background and 
significance of the study, eligibility criteria, and a description of the protocol. To ensure we are 
correctly identifying the potential participant’s LAR, we communicate with members of the clinical 
team. The consent process may need to be modified based on site-specific IRB recommendations.  
 
The name of the study investigator obtaining consent will be clearly documented, and this person will 
sign the informed consent document and provide the date and time of their signature. If a physician 
is performing remote consent, then a copy of the consent form will be signed as soon as he/she is 
physically present. Signed copies of the consent form will be given to the participant/surrogate, and 
the original consent document will be stored in the secure study file. In obtaining and documenting 
informed consent, each investigator will comply with the applicable regulatory requirements and 
adhere to the ethical and Good Clinical Practice principles that have their origin in the Declaration of 
Helsinki.  
 
4.3 Randomization 
After consent is obtained, the research team will notify the local research pharmacy. The research 
pharmacy will be in possession of the randomization list and will determine which arm (intervention 
vs. placebo) the participant will be enrolled in.  
 
Patients should be randomized, consented, and enrolled in the study as soon as possible after 
meeting inclusion criteria. Patients should not be consented if it has been >24hours since the 
patient met inclusion criteria (i.e. start of vasopressors). At the time of randomization and study drug 
administration, the patient should still be receiving a vasopressor. The patient should not be given 
study drug if the vasopressor has been stopped (e.g. patient met inclusion criteria overnight but 
could not be consented for logistical reasons and then improves to the point of no longer requiring a 
vasopressor). In this scenario, the paitent will be entered into the dabase as consented but not 
enrolled.  
 


 
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4.4 Drug preparation and administration 
The vitamin C and vitamin B1 will be mixed together in 100ml of normal saline and administered 
intravenously over 45-60 minutes. The hydrocortisone will be given intravenously as a push-dose in 
1ml of saline over 1-2 minutes. The placebo will be given using techniques and volumes matching 
those of the study medications. 
 
All study medications will be continued for 4-days or until the participant expires or leaves the 
intensive care unit.  
 
4.4.1 Contingencies and Participant Withdrawal  
• In the unlikely event that a participant is discharged alive from the hospital prior to 4 days after 
enrollment, all study medications will be stopped.The participant will remain in the study and will 
be followed for outcomes. 
• Hydrocortisone is occasionally used for refractory septic shock. If the clinical team opts to provide a 
participant hydrocortisone, the hydrocortisone will be given open-label but the vitamin C/B1 will 
remain randomized and blinded. In this case, the research team will ensure that study 
hydrocortisone/placebo is replaced by open-label hydrocortisone. The participant will remain in 
the study and will be followed for outcomes. 
• If the clinical team decides to give the participant vitamin B1 for clinical purposes, the study drug 
will be continued (including thiamine) as long as the total maximum dose of vitamin B1 is 
≤1,500mg/day. 1,500mg day is a standard dose for Wernicke’s encephalopathy at many 
institutions and has not been associated with any increased harm.  
• If the clinical team decides to give the participant vitamin C for clinical purposes, further 
administration of study meds will be stopped. The participant will remain in the study and will be 
followed for outcomes.  
• If a participant withdraws from the study, further administration of study meds will be stopped. 
Data collected prior to withdrawal will be maintained but additional data will not be collected.   
 
4.5 Specimen collection procedures 
4.5.1 Timing and volume of blood draw 
All participants will have a blood samples collected at four time-points and urine samples at two 
time-points (if not already available as part of routine clinical care). Blood will be obtained by 
venipuncture, or from an existing venous or arterial catheter. Urine will be collected via clean catch 
urine or via catheter.  
 
Specimen Collection Time Points 
1. T1=0 hrs (just before study drug administration) 
2. T2=24 hrs (+/- 2 hrs) 
3. T3=72 hrs (+/- 2 hrs) 
4. T4=120hrs (+/- 12hrs) 
 
4.5.2 Specimen samples 
At the T1, T2, T3, and T4 time points, blood will be sent for complete blood count (including 
hemoglobin, white blood cell count, platelet count), a serum chemistry (including sodium, 
potassium, chloride, bicarbonate, blood urea nitrogen, creatining, glucose, aspartate transaminase, 
alanine transaminase, and total bilirubin), and a venous blood gas to measure lactate. These tests 
will be performed by the clinical laboratory at each site. As many of these laboratory tests are 
commonly obtained for clinical purposes, these tests do not need to be repeated if a result is 
available from the clinical care of the participant within 2 hours of the time point (or within 12 hours 
of the T4 time-point).  


 
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In addition to traditional clinical markers, blood will be obtained for future biomarker analysis 
(including inflammatory biomarkers, markers of endothelial function, and markers of mitochondrial 
function), and measurement of vitamin C, vitamin B1, and cortisol levels. The total volume of blood 
that may be drawn for a participant at each time point will not exceed 60mls. Levels of vitamin C, 
vitamin B1, and cortisol will be measured at time T1 and time T3 only. 20ml of urine will be collected 
for future biomarker analysis at T1, T2, and T3. 
 
If performed as part of standard-of-care, results of urinalysis and urine sediment testing will be 
collected prior to enrollment.  
 
4.5.3 Biomarker tube initial processing and shipping 
Please see accompanying blood collection standard operating procedure for full details. In brief, 
15ml of blood will be drawn into EDTA tubes and 10ml of blood will be drawn into a corvac tube. 
From one of the EDTA tubes, 3ml of whole blood will be initially drawn and separated into 3x 1ml 
aliquots. Plasma will then be isolated from the EDTA tube(s) and aliquoted into cryovials as follows: 
4x 0.5ml aliquots and the remainder in 1ml aliquots. Serum will then be isolated from the corvac 
tube, and separated into 1ml aliquots. Cryovials will be protected from light and frozen at -80°C until 
processing. An additional 20ml of urine will also be collected, centrifuged, and separated into 1ml 
aliquots then frozen at -80°C until processing. 
 
Sites will be expected to ship frozen samples to the coordinating center after every 5 enrollments. 
The coordinating center will assist with all shipping procedures.  
 
4.6 Study flow diagram 
 
 
 
4.7 General Sepsis Management  
Investigators should follow local sepsis management guidelines. No specific sepsis bundle is 
required by this study, however the early administration of antibiotics, maintenance of a mean 
arterial pressure ≥65mmHg with a combination of volume resuscitation and vasopressors, and early 
source control are recommended—as detailed in the Suriving Sepsis Guidelines.55 Elements of 
sepsis care should be reported on the online case report form (CRF). 


 
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4.8 Glucometer use during the study period 
High dose vitamin C has been shown to falsely elevate glucose level readings when measured with 
certain point-of-care glucometers employing glucosedehydrogenase-pyrroloquinoline quinone 
amperometric methods56. Some commonly used glucometer brands using this approach include 
Accu-Chek (Roche Diagnostic) and Optium (Abbott Diabetes Care) (but not StatStrip; Nova 
Biomedical). While the effects of high-dose vitamin C on glucometer readings have been seen 
primarily at higher doses of vitamin C than are intended for use in this trial,56 we recommend that 
sites explore what glocumeters are in use in local ICUs. If locally used glucometers may be 
impacted by high serum concentrations of vitamin C (as determined by the manufacturer), we 
recommend that clinical teams caring for enrolled participants be alerted to the possibility of falsely 
elevated blood-glucose levels when measured by glucometer. If there is a clinical concern about a  
glucose reading obtained via glucometer, a serum glucose should be obtained which will not be 
impacted by vitamin C. In the event of an emergency related to suspected hypoglycemia, glucose 
should be immediately given while a serum glucose level is pending.  
 
5. OUTCOMES 
5.1 Definitions 
5.1.1 Primary Outcome 
The primary outcome will be the absolute change in the Sequential Organ Failure Assessment 
(SOFA]) score from enrollment (time=0) to 72 hours after drug administration. The SOFA score will 
be defined using a modification in which the SaO2/FiO2 ratio is substituted for the PaO2/FiO2 ratio 
as has been previously described.57,58 This modified score will be used so that participants without 
an existing arterial catheter can be spared arterial puncture.  
 
Points 
SaO2*/FiO2§ 
Blood Pressure 
GCS‖ 
Bilirubin 
(mg/dL) 
Creatinine 
(mg/dL) 
Platelets 
(x103µL) 
1 
<400 
< 70 mm/Hg 
13–
14 
1.2–1.9 
1.2 – 1.9 
<150 
2 
<326 
dopamine ≤ 5 µg/kg/min or 
dobutamine  
(any dose) 
10–
12 
2–5.9 
2.0 – 3.4 
<100 
3 
<236 (and receiving 
invasive or non-invasive 
mechanical ventilation) 
dopamine > 5µg/kg/min, 
epinephrine/norepinephrine  
≤ 0.1 µg/kg/min 
6–9 
6–11.9 
3.5 – 4.9 
Or 
UOP†<500ml/day 
<50 
4 
<151(and receiving 
invasive or non-invasive 
mechanical ventilation) 
dopamine > 15, 
epinephrine/norepinephrine 
> 0.1 µg/kg/min  
<6 
>12 
> 5.0 
UOP†<200ml/day 
Or receiving 
renal 
replacement 
therapy 
<20 
*SaO2=Oxygen saturation (%); § = Fraction of inspired oxygen (%); ‖ = Glasgow Coma Scale; † = Urine Output 
Fio2 will be determined by using either the set FiO2 (for patients receiving invasive or non-invasive 
mechanical ventilation) or by adding 3% FiO2 for each liter/minute of supplemental oxygen added 
up to 100% FiO2 (for patients not receiving mechanical ventilation). Patients with an SaO2/FiO2 
ratio <236 who are not receiving invasive or non-invasive mechanical ventilation, will be assigned a 
score of 2.  
 
5.1.2 Key Secondary Outcomes 
Incidence of Acute Renal Failure – Renal failure will be defined as the development of Kidney 
Disease Improving Global Outcomes [KDIGO] Stage 3 acute kidney injury during the index ICU stay 
after study enrollment.58 


 
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KDIGO Stage 
Serum creatinine criteria 
Urine output criteria 
1 
Increase in serum creatinine of 
more than or equal to 0.3 mg/dl (≥ 
26.4 μmol/l) or increase to more 
than or equal to 150% to 200% (1.5- 
to 2-fold) from baseline 
Less than 0.5 ml/kg per hour for 
more than 6 hours 
2 
Increase in serum creatinine to 
more than 200% to 300% (> 2- to 3-
fold) from baseline 
Less than 0.5 ml/kg per hour for 
more than 12 hours 
3 
Increase in serum creatinine to 
more than 300% (> 3-fold) from 
baseline (or serum creatinine of 
more than or equal to 4.0 mg/dl [≥ 
354 μmol/l] with an acute 
increase of at least 0.5 mg/dl [44 
μmol/l])  
Less than 0.3 ml/kg per hour for 
24 hours or anuria for 12 hours 
OR 
New renal replacement therapy 
(RRT) 
 
30-Day Mortality – Mortality at 30-days. This will be assessed by review of the medical records if the 
participant remains in the hospital or if the participant expired while in the hospital. If the participant 
was discharged, 30-day mortality will be assessed by contacting the participant by phone or by 
searching the National Center for Health Statistics (NCHS) National Death Index (NDI) consistent 
with a recent multicenter phase III trial in sepsis.23 Phone calls will be made by the research team at 
each site.  
 
5.2 Rationale for Outcomes  
Change in SOFA score: Organ failure is highly associated with mortality60 and improvement in 
organ function is a key goal for critical care physicians. In the study by Marik et al.36, participants 
who received the 3-drug regimen had substantial improvements in the trajectory of organ failure 
over the first 72-hours of their ICU stay. If the combination of vitamin C, hydrocortisone, and vitamin 
B1 can improve organ function in the first 72-hours following ICU admission, we believe that 
clinicians will likely quickly adopt this safe and inexpensive therapy. Importantly, this outcome can 
be measured early in the hospital stay and is therefore less likely to be affected by other potential 
elements of hospital care that can affect more distal outcomes (e.g., mortality).  
 
Kidney Injury: Renal failure has been estimated to occur in 23% of participants with sepsis and 
over 50% of participants with septic shock.61 In studies of participants with septic shock, there is a 
step-wise increase in mortality with worsening acute kidney injury (AKI).62 In addition, many 
participants who experience renal injury during septic shock do not recover renal function prior to 
hospital discharge and may require long term dialysis. As both data from the study by Marik et. al.36 
and a separate study of vitamin B1 in septic shock38 have shown substantial improvements in renal 
outcomes, kidney failure is a natural secondary outcome and one that could change practice 
independently from other factors – in other words, many clinicians would likely provide this therapy if 
they knew that kidney function could be protected, since this organ is vital to long-term health. 
 
Mortality: Finally, we will measure 30-day mortality. We anticipate that the combination of vitamin 
C, hydrocortisone, and vitamin B1 will reduce mortality in this high-risk population.  
 
5.3 Additional Secondary Outcomes 
5.3.1 Additional secondary outcomes 
Additional secondary outcomes will include length of ICU stay, length of hospital stay, ventilator-free 
days over the first 7-days after enrollment, shock-free days over the first 7-days after enrollment, 


 
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and the incidence of delirium on day #3 of the ICU stay (as assessed using the Confusion 
Assessment Method [CAM-ICU] system).63 Sites at which the CAM-ICU is performed daily as part of 
standard-of-care should assess whether delirium occurs on any day during the initial ICU stay. See 
Appendix #2.  
 
5.3.2 90-day follow-up for Quality of Life assessment 
Sites may choose to participate in a long-term outcomes substudy exploring the effects of ascorbic 
acid, hydrocortisone, and thiamine vs. placebo on quality of life following sepsis. If a site chooses to 
participate, a trained research assistant/investigator at the site (who is blinded to treatment arm) will 
contact all participants who were alive at 30-days, and perform the SF-36 at day 90 following 
enrollment. The SF-36 is a 36-Item Short-Form Health Survey (SF-36), a validated survey of general 
quality of life in adults, can be administered in person or over the telephone by research personnel. It 
measures eight different dimensions: physical functioning, bodily pain, role limitations due to physical 
health problems, role limitations due to personal or emotional problems, emotional well-being, social 
functioning, energy/fatigue, and general health perceptions, as well as one question asking about 
perceived changes in health. The telephone version of the 36-Item Short-Form Health Survey has 
been validated64,65 and used in sepsis.66-69  
 
5.4 Safety 
5.4.1 Definitions  
The following definitions will be used70:  
 
Adverse event: any untoward medical occurrence in a participant to whom a medicinal product is 
administered and which does not necessarily have a causal relationship with this treatment 
 
Serious adverse event: any untoward medical occurrence that at any dose requires inparticipant 
hospitalization or prolongation of existing hospitalization, results in persistent or significant disability 
or incapacity, results in a congenital anomaly or birth defect, is life-threatening, or results in death 
 
Unexpected serious adverse event: a serious adverse reaction, the nature, severity or outcome of 
which is not consistent with the reference safety information 
 
 
5.4.2 Specific adverse event data collection 
To assess specific amd potentially serious adverse events that may be related to the combination of 
the study medications, we will collect data on the following:  
 
Serious Adverse Event 
Definition 
Hyperglycemia 
Serum glucose >300mg/dl in the first 120-hours after 
enrollment 
Hypernatremia 
Serum sodium (> 150 mmol/L) occurring in the first 120-
hours after enrollment 
New Infection 
As determined by the site principal investigator at each 
site. Should be a new organism or site of infection and 
believed to be unrelated to the initial presenting 
infectious source. Many will have the initiation of new 
antibiotics or a change in antibiotics. 
Catheter-site 
Lung 
Gastrointestinal 
Urinary tract 
Other 
Serious allergic reaction 
Anaphylaxis or other allergic reaction requiring systemic 
corticosteroids. Allergic reaction should be related (or 
suspected to be related) to the study medicaiton  
Renal calculus 
Development of a renal calculus between enrollment 
and 30-day follow-up (based on question asked during 
follow-up phone call). 


 
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5.4.3 Adverse Event Reporting 
All unexpected serious adverse events thought to be related to the study drug, and any 
unexpected fatal or life-threatening adverse events thought to be related to the study drug 
will be recorded in the online CRF, reported directly to the coordinating center, and reported 
to the appropriate IRB shortly following the event per local protocol. In addition, unexpected 
serious adverse events related to the study drug will be undergo expedited reporting to the 
DSMB within 7 days of the coordinating center becoming aware of the event. The DSMB will 
additionally review all adverse events in aggregate after every 50 patients are enrolled. 
 
Adverse events will additionally be reported to the FDA as outlined in 21CFR312.32 and 
summarized below: 
a. All unexpected fatal or life-threatening adverse events thought to be related to the 
study drug will be reported to the FDA within 7 calendar-days of when the ACTS 
team is made aware of the event. 
b. All unexpected serious adverse events thought to be related to the study drug will be 
reported to the FDA within 15 calendar-days of when the ACTS team is made aware.  
c. All serious unexpected adverse events, and any unexpected fatal or life-threatening 
events thought to be related to the study drug, will be reported back to all site 
investigators within 15 calendar-days of the event. 
d. The ACTS team will periodically review all published information relating to the safety 
of each element of the drug combination. Any concerning safety information obtained 
from this review, or otherwise obtained (e.g. from unpublished scientific papers), will 
be reported to the FDA within 15 calendar-days. 
 
5.4.5 Safety Monitoring Labs 
As detailed above, safety monitoring labs will be obtained at 120-hours, after completion of the 
study protocol.  
 
6. SAMPLE SIZE CALCULATION AND STATISTICAL ANALYSIS PLAN  
6.1 Sample size calculation 
The study has been powered to have at least 80% power for the primary outcome and all key 
secondary outcomes as follows: 
 
SOFA Score: Based on preliminary data36, we conservatively anticipate a decrease in SOFA score 
of 6 (standard deviation [SD]: 4) in the treatment group and 4 (SD: 2) in the placebo group. With 
these estimates, enrollment of 200 participants (100/arm) at an alpha of 0.05 and using a t-test 
with unequal variance, the trial will provide > 99% power to detect a statistical significant difference 
between groups.  
 
Kidney Injury: Based on preliminary data from our study of vitamin B1 in septic shock,38 we 
anticipate that 30% of participants in the treatment group and 55% in the placebo group will have 
renal failure which will result in a 94% power for this outcome. This calculation and following 
calculation were performed using the Fisher’s exact test. 
  
Mortality: Based on preliminary data36,37,71, we anticipate that the control group will have a mortality 
of 40%. We estimate a treatment effect of 50% (risk ratio: 0.50) resulting in a mortality of 20% in the 
treatment group. With these estimates, 182 participants will lead to 80% power. To further increase 


 
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the trial’s power and due to potential loss-to-follow-up, we will aim to enroll 200 participants. These 
estimates are conservative compared to the Marik et al. study which found a treatment effect 
corresponding to a risk ratio of 0.21 which persisted in adjusted analysis.36  
 
Sample Size Adjustment 
 
If after 100 patients are enrolled, the overall change in SOFA score is less than anticipated in the 
above power analysis and/or the renal failure event rate or mortality rate is lower than predicted, the 
enrollment target of 200 patients may be adjusted accordingly so as to improve power for the 
primary outcome and all key secondary outcomes at the end of the trial period. Specifically, we will 
aim to maintain ≥90% power to detect a 2-point difference in ΔSOFA score (using variance seen for 
the full cohort) and ≥80% power to detect a 50% treatement effect on mortality. Whether to increase 
the study sample size, and the degree of sample size increase, will be decided on by the blinded 
Steering Committee who will not have access to data stratified by treatment group. The Steering 
Committee will take into account logistical and financial considerations when updating the 
enrollment target.  
 
6.2 Statistical analysis plan 
6.2.1 General considerations 
The statistical analyses and reporting will adhere to the CONSORT guidelines.72,73 All tests will be 
two-sided, a p-value < 0.05 will be considered significant, and all confidence intervals will have 95% 
coverage. All analyses will be conducted on a modified intention-to-treat basis only including 
participants receiving at least the first dose of the study medications. In a double-blind trial, this 
approach is unbiased while increasing precision.74 The two groups will be compared in relation to 
baseline characteristics using descriptive statistics.  
 
The persons conducting the statistical analysis will be blinded to the randomized allocation. Groups 
will be designated as “A” and “B” until all pre-specified analyses are performed and shared with all 
authors and the Data Safety Monitoring Board. 
 
6.2.2 SOFA score and renal failure 
The change in SOFA score will be calculated and compared between groups using the Wilcoxon 
Rank Sum test (if the change is not normally distributed) or by a t-test if the change is approximately 
normally distributed. Fisher’s exact tests will be used to compare the incidence of renal failure 
during the index ICU stay. 
  
If a participant expires prior to the 72-hour time point, SOFA scores will be imputed based on a pre-
defined plan as follows. If a participant expires before 24-hours has elapsed, a 20% increase from 
baseline will be imputed. If a participant expires between 24-hours and 48-hours, a 15% increase 
from the 24-hour time point will be imputed. If a participant dies between 48-hours and 72-hours, a 
20% increase from the 24-hour time point will be imputed. Sensitivity analyses will be performed using 
various other imputation techniques. Specifically, we will perform 1) a sensitivity analysis in which the 
worst possible SOFA score (score of 24) is imputed for those participants who expire, 2) a sentivity 
analysis in which the last SOFA score for participants who expire will be carried forward, and 3) a 
sensitivity analysis in which only those patients who survive to 72-hours are included. These 
sensitivity analyses were chosen to model ‘worst-possible’ and ‘best-possible’ scenarios. For the 
secondary outcome of renal failure, participants who expire during their ICU stay will be assessed to 
have developed renal failure if they demonstrated any degree of unresolved KDIGO acute kidney 
injury prior to death. If there was no evidence of acute kidney injury prior to death or if kidney injury 
had fully resolved, these participants will be assessed as not having developed renal failure.  


 
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6.2.3 30-day mortality 
Survival until 30 days will be analyzed using survival analysis. Participants lost to follow-up will be 
censored and the censoring will be assumed non-informative. Results will be presented with 
Kaplan-Meier curves and the groups compared using the log-rank test.75 Hazard ratios with 95% 
confidence intervals will be obtained using Cox’s proportional hazards models.76 The proportional 
hazards assumption will be verified by visual inspection of the Kaplan-Meier curves and statistically 
by including a product term (i.e. “interaction”) between the treatment group variable and the natural 
logarithm of time in the model.77 If the proportional hazards assumption is not met, only the Kaplan-
Meier curves and the p-value from the log-rank test will be presented. 
 
Adverse events and other binary outcomes will be presented and analyzed like renal failure. 
 
6.2.4 Additional Secondary Analyses 
Both ICU and hospital length of stay will be compared using Wilcoxon Rank Sum tests. Ventilator 
and shock free days over the first 7-days after enrollment will likewise be compared using the 
Wilcoxon Rank Sum given that the data will likely be not normally distributed. In these latter two 
analyses, patients who expire prior to 7-days will be assessed to have 0 ventilator or shock free 
days if they had died while on a ventilator or vasopressor respectively. The incidence of delirium will 
be compared using the Fisher’s exact test. For the quality-of-life outcome (i.e. 90-day SF-36), the 
primary analysis will only include patients with available data. As a secondary analysis, multiple 
imputation will be used to estimate SF-36 scores in all patients not known to be dead at 90 -days. 
 
6.2.5 Subgroup analyses  
The analysis will include three pre-defined subgroup analyses for the primary and key secondary 
outcomes according to 1) participants with initially high SOFA scores (≥9). This cut-off was chosen 
to represent a population with a ≥50% predicted likelihood of mortality78 2) baseline vitamin B1 
deficiency and 3) baseline adrenal insufficiency. We will not plan to perform a subgroup analysis 
according to vitamin C deficiency, as prior work has shown that the vast majority of participants with 
septic shock have vitamin C levels below the reference range.36 Vitamin B1 deficiency will be 
defined as a plasma vitamin B1 level ≤ 7 nmol/L as has been previously described.37 Adrenal 
insufficiency will be defined as a cortisol level <10µg/dL.43 The trial is not powered to detect 
subgroup differences and these will be considered exploratory and hypothesis generating.    
 
6.2.6 Statistical stopping criteria  
Since the primary outcome is not mortality, there will be no formal stopping criteria for efficacy. 
There will be no predefined stopping criteria for futility since enrollment of the full cohort might allow 
for detection of efficacy in subgroups or in other outcomes even if the primary outcome is negative.  
 
7. DATA COLLECTION AND MANAGEMENT  
7.1 Data collection process  
Data collection will be the responsibility of the individual site investigators with oversite from the trial 
coordinating center. Most variables (i.e. demographics, sepsis characteristics and laboratory 
results) will be obtained prospectively from the electronic medical record. 30-day follow-up 
regarding safety and mortality end-points will be obtained via telephone call post-discharge (unless 
the participant remains in the hospital at 30-days). Data will be entered directly into the online 
database software (see below).  
 
7.2 Variables 
Will be provided on the online CRF. A PDF version is available upon request. 
 


 
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7.3 Data quality and validity  
Data quality and validity will be optimized by using a detailed data dictionary which will be 
distributed to all sites. Data quality will be monitored both centrally by the coordinating site and 
locally by each site principal investigator.  
 
7.4 Data storage and security  
The database application we will use is REDCap Cloud (https://www.redcapcloud.com/). REDCap 
Cloud is a professional database that provides a user-friendly interface. The REDCap Cloud data 
management system is secure, fully compliant with all regulatory guidelines, and includes a 
complete audit-trail for data entry validation. Through these mechanisms, as well as relevant 
training for all involved parties, participant confidentiality will be safeguarded. All members of the 
research team will be required to complete standardized training in REDCap cloud, which will be 
documented within the software.  
 
The consent form and other trial documents for each participant will initially be stored in a secure, 
locked place at the individual sites. Participating sites will be responsible for maintaining their own 
trial documents and study materials (e.g. signed ICFs, site logs etc). Trial documents generated at 
the Coordinating Center will be maintained the Coordinating Center. Following completion of the 
trial, documents will be maintained for a period of at least 2-years at each site per FDA regulations 
(or longer depending on local IRB guidelines). 
 
8. ETHICAL CONSIDERATIONS  
8.1 Risks and Benefits  
8.1.1 Potential benefits 
Potential Benefits to Individual Participant: Assuming our hypothesis is correct and our results are 
comparable to those previously published36, individual participants enrolled in our study and 
randomized to the treatment arm will benefit from a better trajectory of organ failure and improved 
mortality. As many participants who survive an initial episode of sepsis will have a future admission for 
sepsis, participants participating in this study but randomized to the placebo arm may see a future 
benefit from knowledge gained. 
 
Potential Benefits to Society: Septic shock remains a highly morbid clinical condition for which there 
is no specific therapy. Our study, assuming our hypothesis is confirmed, will provide strong support for 
the widespread adoption of vitamin C, corticosteroids, and vitamin B1 for participants with septic 
shock. This, in turn, will significantly improve participant outcomes and reduce the global burden of 
death related to septic shock. Thus, even if participants are randomized to the placebo arm, their 
involvement with this study has tremendous potential benefits for society as whole. If vitamin C, 
corticosteroids, and vitamin B1 are found to be neutral or harmful (the latter being highly unlikely), 
society will benefit as the study will likely prevent the widespread dissemination of an ineffective 
medication combination.  
 
8.1.2 Potential harms  
Study Drug  
Vitamin C – Ascorbic acid is a water-soluble essential vitamin that is safe even at high doses. 
Nevertheless, adverse effects related to high-dose ascorbic acid have been described. These 
adverse effects include diarrhea/abdominal bloating, increased oxalate excretion, iron overload in 
participants with hemochromatosis, and hemolysis in participants with G6PD deficiency.79  We 
exclude participants with known renal failure,  known G6PD deficiency, or known hemochromatosis 
to limit these potential risks. We will additionally exclude participants with known allergy to ascorbic 


 
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acid. Ascorbic acid has additionally been used in at least 3 clinical trials in critically-ill populations 
without major associated adverse effect.40-42 
 
Hydrocortisone – Hydrocortisone is a well-established medication for the treatment of refractory 
shock in sepsis. Some studies (e.g. CORTICUS) have found an increased incidence of secondary 
infection in participants with septic shock who receive steroids.46 This finding has not been 
replicated in other large trials of corticosteroids for sepsis.47 Additional hypothetical risks to the 
administration of hydrocortisone to participants with septic shock (e.g. increased gastro-intestinal 
bleeding, muscle weakness, and delirium) have not been found in clinical trials of corticosteroids in 
sepsis.46,47 Finally, hydrocortisone may increase the risk of hyperglycemia and hypernatremia.  
 
Hydrocortisone will not be tapered in this study as prior studies have shown benefit with 
corticosteroids in septic shock without a taper.80 In addition, a recent large trial of corticosteroids in 
septic shock (ADRENAL, NEJM 2018) randomized patients to 7-days of corticosteroids or placebo 
and did not include a taper. In that trial there was no reported difference in rates of recurrent shock. 
 
Vitamin B1 – The only potential serious side effect that has been reported from vitamin B1 
administration is an extremely rare anaphylactic reaction (1:250,000 cases) and this might not even 
be of issue with the current manufactured version of vitamin B1 in the United States. The risk of an 
anaphylactic reaction was associated with a vitamin complex dispensed in Europe, and whether 
vitamin B1 was the actual offending agent remains unknown; however, this 0.0004% theoretical 
chance of an adverse reaction is incredibly low. In a series of 989 participants in the United States 
who received intravenous vitamin B1, none had an anaphylactic reaction and the only reported side 
effects were minor consisting of transient local irritation or in one case pruritus (0.093%).81 Further 
safety data comes from the clinical use of intravenous vitamin B1 at our coordinating site.  At Beth 
Israel Deaconess Medical Center (BIDMC, coordinating center) vitamin B1 is provided liberally for 
participants with nutritional deficiency – for example, BIDMC has administered intravenous vitamin 
B1 in over 8,000 separate participant encounters from 2002 until present. Despite this heavy usage, 
no adverse reactions were reported in any of the 8,000 participant encounters.    
 
The combination of vitamin C, hydrocortisone and vitamin B1 – To date, the only study of the 
combination of vitamin C, hydrocortisone and vitamin B1 was the above referenced study by Marik 
et. al.  
 
All procedures will take place at the study site. All research procedures and monitoring will be 
conducted by experienced personnel, and participants will be in the ICU given critical illness. This 
permits closer observation and more detailed monitoring by clinicians familiar with the care of 
participants experiencing and resuscitated from septic shock. 
 
Blood Collection 
Most participants will have existing venous or arterial catheters in place and we will be able to collect 
blood from these ports, essentially eliminating the risks associated with blood collection. In the very 
rare case that a participant does not have an indwelling line, the risk of venipuncture is extremely low, 
and will not exceed the risk of clinical blood draws the participant will already be receiving. 
 
Loss of Confidentiality 
All measures will be taken to ensure that no confidential information is released. All participant 
information will be stored in a password protected database to which only study investigators will 


 
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have access. Additionally, all hard copies of study data will be kept in a locked office accessible only 
to study investigators. Thus, the risk of loss of confidentiality is very low. 
 
9. MONITORING 
9.1 Institutional Review Board (IRB) 
The study will be reviewed and approved by the IRB at each participating site.  
 
9.2 Data Safety and Monitoring Board (DSMB) 
The DSMB will be responsible for safeguarding the interests of trial participants, assessing the 
safety and efficacy of the interventions during the trial, and for monitoring the overall conduct of the 
clinical trial. The DSMB will consist of three clinicians with critical care experience in the 
management of septic participants. An independent biostatistician/epidemiologist will prepare all 
DSMB reports. The DSMB members will be chosen such to avoid any financial or intellectual 
conflicts of interest. The DSMB will review deidentified data after every 50 participants are enrolled 
to assess for safety; unless there are group differences necessitating unblinding (as determined by 
the DSMB), the DSMB will be blinded to treatment groups. The trial will continue while the DSMB 
review data. After each review, the DSMB will create a short report to the steering committee with 
recommendations for continuation, modifications, or termination of the trial. Criteria for 
recommending termination will be at the discretion of the DSMB and there will be no formal 
statistical criteria for termination due to efficacy or safety. A detailed charter for the DSMB will be 
provided.  
 
DSMB Members 
Clifton Callaway, MD, PhD  
University of Pittsburgh 
400A Iroquois 
Pittsburgh, PA 15260 
(412) 647-8287 
callawaycw@upmc.edu 
Professor (tenured) of Emergency Medicine; Executive Vice-Chair of Emergency Medicine; UPMC 
Professor of Emergency Medicine Research 
Expertise: Cardiac Arrest/Clinical Trials  
 
Taylor Thompson, MD  
Massachusetts General Hospital 
55 Fruit Street 
Boston, MA 02114 
(617) 724-7823 
tthompson1@partners.org 
Professor of Medicine, Harvard Medical School 
Director, Critical Care Translational Research, Pulmonary/Critical Care Unit, MGH 
Medical Director, ARDS Network Clinical Coordinating Center  
Expertise:  Sepsis/Clinical Trials 
 
Shahzad Shaefi, MD MPH [DSMB Chair] 
Beth Israel Deaconess Medical Center 
One Deaconess Raod 
Boston, MA 02115 
(617) 355-6286 
sshaefi@bidmc.harvard.edu 
Attending Physician, Department of Anesthesia, Critical Care and Pain 


 
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Expertise:  Critical Care Medicine 
 
10 CLINICAL MONITORING PLAN 
The detailed clinical monitoring plan has been developed and is available from the Coordianting 
Center upon request. 


 
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11. TIMELINE AND ENROLLMENT  
11.1 Timeline  
 
Pre-trial 
Months 0-5 
Months 6-11 
Months 12-18 
Funding 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol development and 
modifications 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FDA IND approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethical approval 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Registration with 
Clinicaltrials.gov 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Creation of data dictionary  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Creation of randomization 
list 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Site start-up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Education of site 
personnel  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DSMB monitoring 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrollment and 
assessment of outcomes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cleaning and closing of 
the database 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unblinding & Data analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Main manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Publication and 
presentation of results 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
11.2 Screening & Enrollment  
Enrollment at each site will be continuously monitored by the site investigator and the principal 
investigator. Each site will be expected to maintain a screening log including all participants who 
meet all eligibility criteria at that site. A standardized screening log will be provided to each site via 
RedCap Cloud—thus allowing for continuous updating of the screening log and will allow capture of 
all screening failures.    


 
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Enrollment will be competitive (i.e. without specific enrollment caps). Number of enrollments at each 
site will be shared with all sites on a monthly basis. Sites will be expected to complete all elements 
of the online CRF within 48-hours of each time point. In the case that a site continuously 
underperforms despite troubleshooting and feedback, the steering committee will evaluate whether 
enrollment will continue at that site. 
 
12. FUNDING 
Funding for the present trial is provided by the Good Ventures Foundation 
(http://www.goodventures.org/). The funding agency will have no role in the design and conduct of 
the study, collection, management, analysis, and interpretation of the data, preparation, review, or 
approval of the manuscript, or the decision to submit the manuscript for publication.  
 
13. PUBLICATION 
The manuscript will adhere to the CONSORT guidelines.72,73 The principal investigator will be 
responsible for assigning authorship position and will follow authorship guidelines from the 
International Committee of Medical Journal Editors.82 At a minimum, all members of the Steering 
Committee and all site Principal Investigators (for sites enrolling at least 10 participants) will be 
included in the primary author list. The main results will be presented at an international conference. 
The trial results will be shared with participating sites and via press releases but not directly with the 
participants. 
 
14. DATA SHARING 
Six months after the publication of the last results, all de-identified individual participant data will be 
made available for data sharing.83 Procedures, including re-coding of key variables, will be put in 
place to allow for complete de-identification of the data. All relevant trial-related documents, 
including the protocol, data dictionary, and the main statistical code, will be shared along with the 
data. There will be no predetermined end date for the data sharing. Data will be available for any 
research purpose to all interested parties who have approval from an independent ethics review 
committee and who have a methodological sound proposal as determined by the steering 
committee of the current trial. Interested parties will be able to request the data by contacting the 
principal investigator. Authorship of publications emerging from the shared data will follow standard 
authorship guidelines from the International Committee of Medical Journal Editors82 and might or 
might not include authors from the steering committee depending on the nature of their involvement.  
 
15. TASKS AND RESPONSIBILITIES  
Principal investigator and sponsor: Overall responsibility for protocol development, funding, budget 
overview, data dictionary development, ethical approval, trial registration, daily management, trial 
oversight and collection of adverse events, contact to the pharmacy, contact to Good Clinical 
Practice monitoring unit and the data and safety monitoring board, assessment of overall 
recruitments, potential recruitment of additional sites, data analysis, and dissemination and 
presentation of results.  
 
Steering committee: Protocol development, funding, budget overview, data dictionary development, 
trial oversight, dissemination of results, responsibilities as principal investigator for short time 
periods.  
 
Site investigators: Responsible for site-specific enrollment, evaluation of eligible patients not 
included, education of personnel at participating sites, reporting of site-specific issues or challenges 
to the principal investigator, participant consent for data collection, collecting and reporting data 
regarding adverse drug events. 


 
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Clinical team: Administration of the study drug, participant consent for data collection.  


 
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Appendices 
 
Appendix 1: Abbreviations 
ICH………………..International Conference on Harmonization 
SPIRIT………………..Standard Protocol Items: Recommendations for Interventional Trials  
ACT………………..Ascorbic Acid, Corticosteroids, and Thiamine  
ESRD………………..End Stage Renal Disease 
SOFA………………..Sequential Organ Failure Assessment 
IND………………..Investigational New Drug 
FDA………………..Food and Drug Administration 
ICU………………..Intensive Care Unit 
SaO2………………..Oxygen Saturation 
FiO2………………..Fraction of Inspired Oxygen 
GCS………………..Glasgow Coma Scale 
UOP………………..Urine Output 
RRT………………..Renal Replacement Therapy 
CAM………………..Confusion Assessment Method 
NCHS……………….. National Center for Health Statistics 
NDI………………..National Death Index 
AKI………………..Acute Kidney Injury 
SD……………….. tandard deviation 
CRF………………..Case Report Form 
BIDMC………………..Beth Israel Deaconess Medical Center (Coordinating Center) 
IRB………………..Institutional Review Board 
DSMB………………..Data Safety and Monitoring Board 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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Appendix 2: CAM-ICU Form