Study objective: To assess the effects of adjunctive treatment with N-acetyl-L-cysteine (NAC) on hemodynamics, oxygen transport variables, and plasma levels of cytokines in patients with septic shock.
Design: Prospective, randomized, double-blind, placebo-controlled study.
Setting: A 24-bed medicosurgical ICU in a university hospital.
Patients: Twenty-two patients included within 4 h of diagnosis of septic shock.
Interventions: Patients were randomly allocated to receive either NAC (150 mg/kg bolus, followed by a continuous infusion of 50 mg/kg over 4 h; n=12) or placebo (n=10) in addition to standard therapy.
Measurements: Plasma concentrations of tumor necrosis factor-α (TNF), interleukin (IL)-6, IL-8, IL-10, and soluble tumor necrosis factor-α receptor-p55 (sTNFR-p55) were measured by sensitive immunoassays at 0, 2, 4, 6 and 24 h. Pulmonary artery catheter-derived hemodynamics, blood gases, hemoglobin, and arterial lactate were measured at baseline, after infusion (4 h), and at 24 h.
Results: NAC improved oxygenation (PaO2/FIO2 ratio, 214±97 vs 123±86; p<0.05) and static lung compliance (44±11 vs 31±6 L/cm H2O; p<0.05) at 24 h. NAC had no significant effects on plasma TNF, IL-6, or IL-10 levels, but acutely decreased IL-8 and sTNFR-p55 levels. The administration of NAC had no significant effect on systemic and pulmonary hemodynamics, oxygen delivery, and oxygen consumption. Mortality was similar in both groups (control, 40%; NAC, 42%) but survivors who received NAC had shorter ventilator requirement (7±2 days vs 20±7 days; p<0.05) and were discharged earlier from the ICU (13±2 days vs 32±9 days; p<0.05).
Conclusion: In this small cohort of patients with early septic shock, short-term IV infusion of NAC was well-tolerated, improved respiratory function, and shortened ICU stay in survivors. The attenuated production of IL-8, a potential mediator of septic lung injury, may have contributed to the lung-protective effects of NAC.