Vitamin C and Surgery
Oral Surg Oral Med Oral Pathol. 1982 Mar;53(3):231-6.
Vitamin C and human wound healing.
Clinical studies provide evidence that wound healing in subjects judged not deficient in vitamin C can be significantly accelerated with supplements of this nutrient above the recommended daily allowance (RDA). The authors administered daily dosages of 500 to 3,000 mg., which is roughly 8 to 50 times the RDA of 60 mg., to subjects recovering from surgery, other injuries, decubital ulcers, and leg ulcers induced by hemolytic anemia. Genetic impairment of collagen synthesis has also been observed to be responsive to ascorbic acid supplementation in an 8-year-old boy with Type VI Ehlers-Danlos syndrome. Four grams of ascorbic acid daily produced a significant improvement in the quality of newly synthesized collagen but did not alter that formed prior to the supplementation of C. The combined evidence in this review provides a substantial base for further research, both clinical and experimental trials, concerning the interrelationships between vitamin C and the body’s healing potential.
J Surg Res. 2005 Nov;129(1):46-51. Epub 2005 Aug 8.
Metabolic clearance of the antioxidant ascorbic acid in surgical patients.
Rümelin A1, Humbert T, Lühker O, Drescher A, Fauth U.
A reduction of plasma ascorbic acid concentration in the post-operative period has been well documented and is associated with an increase in post-operative complications. The underlying reason for the decreased concentration of ascorbic acid in the plasma is not clear. However, only an increased post-operative requirement for ascorbic acid would justify a substitution. Therefore, we investigated the pre-operative and post-operative metabolic clearance of ascorbic acid.
MATERIALS AND METHODS:
We calculated the metabolic clearance subsequent to intravenous bolus injection of 6 mg ascorbic acid/kg body weight in 15 patients before and after they underwent major maxillofacial surgery. Blood samples were taken before and 5, 15, 30, 45, 60, 90, 120, and 240 min after administration of ascorbic acid before and after the operation. Urine was collected. Ascorbic acid in plasma and urine was analyzed using a high performance liquid chromatographic technique.
The pre-operative metabolic clearance was 7.6 +/- 2.22 l/h (mean +/- SD), increasing significantly to 12.1 +/- 4.87 l/h on the first post-operative day (P < 0.001). Doses of approximately 1150 mg ascorbic acid would be necessary to compensate for the observed loss and to raise plasma ascorbic acid to high normal values.
There is a significantly increased post-operative metabolic clearance of ascorbic acid that might be considered when framing future dose recommendations in post-operative patients.
J Surg Res. 2003 Feb;109(2):144-8.
Ascorbic acid dynamics in the seriously ill and injured.
Long CL1, Maull KI, Krishnan RS, Laws HL, Geiger JW, Borghesi L, Franks W, Lawson TC, Sauberlich HE.
In addition to the known beneficial effects of ascorbic acid on wound healing and the immune response, it is also a potent extracellular antioxidant. Recent work in septic rats suggests that high-dose ascorbic acid total parenteral nutrition (TPN) supplementation may protect cells from free radical injury and improve survival. In this study, we determined ascorbic acid levels in the immediate post-injury/illness period and evaluated the ability of early short-term high levels of ascorbic acid in TPN to normalize plasma levels.
MATERIALS AND METHODS:
Ascorbic acid levels were determined in 12 critically injured patients and 2 patients with severe surgical infections. Each patient received TPN supplemented with increasing doses of ascorbic acid over a 6-day period. Therapeutic responses were determined by plasma and urine measurements using high-pressure liquid chromatography.
The initial mean +/- SEM baseline plasma ascorbic acid concentration was depressed (0.11 +/- 0.03 mg/dl) and unresponsive following 2 days on 300 mg/day supplementation (0.14 +/- 0.03; P = 1.0) and only approached low normal plasma levels following 2 days on 1000 mg/day (0.32 +/- 0.08; P = 0.36). A significant increase was noted following 2 days on 3000 mg/day (1.2 +/- 0.03; P = 0.005).
We confirmed extremely low plasma levels of ascorbic acid following trauma and infection. Maximal early repletion of this vitamin requires rapid pool filling early in the post-injury period using supraphysiologic doses for 3 or more days.
Arch Gynecol Obstet. 2012 Jan;285(1):111-5. doi: 10.1007/s00404-011-1897-7. Epub 2011 Mar 30.
Intravenous ascorbic acid (vitamin C) administration in myomectomy: a prospective, randomized, clinical trial.
Pourmatroud E1, Hormozi L, Hemadi M, Golshahi R.
To assess the usefulness of using ascorbic acid (vitamin C) administration in abdominal myomectomy.
MATERIALS AND METHODS:
A total of 102 patients were divided two groups in this prospective, clinical trial. Group A had received 2 g of ascorbic acid during a myomectomy, and group B had a myomectomy without any interventions. The operative time, blood loss, days of hospitalization, post-operative complications and rate of blood transfusions were compared between the two groups.
The blood loss (521.44 ± 199.24 vs. 932.9 ± 264.38 ml; p value <0.001), duration of the operation time (42 ± 13.9 vs. 68 ± 21.7 min; p value <0.001), days of hospitalization (2.7 ± 0.69 vs. 3.1 ± 0.59 days; p value 0.002) in group A were significantly less than in group B (p value 0.001). The chance risk ratio of a blood transfusion in group A was 0.4 (7.7 vs. 18% 95% CI of 0.1-1; p value 0.07). There was a significant correlation between the volume of bleeding and post-operative complications in both groups (p value in group A = 0.03; in group B = 0.004).
The administration of ascorbic acid (vitamin C) in abdominal myomectomy could reduce the blood loss during the procedure, operation time and days of hospitalization.
Bull Exp Biol Med. 2000 Nov;130(11):1055-7.
Effects of ascorbic acid on lipid peroxidation and functional state of neutrophils at the early period after transurethral resection of the prostate.
Volchegorskii IA1, Vasil’kov AY.
Intravenous infusion of ascorbic acid in single doses of 500 and 1000 mg over 3 days after transurethral resection of the prostate elevated the content of lipid peroxidation products in the blood, increased the sensitivity of neutrophils to prodigiozan, and reduced the risk of infectious and inflammatory complications.
Crit Care. 2014 Aug 6;18(4):460. [Epub ahead of print]
Vitamin C revisited.
Oudemans-van Straaten HM, Man A, de Waard MC.
This narrative review summarizes the role of vitamin C in mitigating oxidative injury-induced microcirculatory impairment and associated organ failure in ischemia/reperfusion or sepsis. Preclinical studies show that high-dose vitamin C can prevent or restore microcirculatory flow impairment by inhibiting activation of nicotinamide adenine dinucleotide phosphate-oxidase and inducible nitric oxide synthase, augmenting tetrahydrobiopterin, preventing uncoupling of oxidative phosphorylation, and decreasing the formation of superoxide and peroxynitrite, and by directly scavenging superoxide. Vitamin C can additionally restore vascular responsiveness to vasoconstrictors, preserve endothelial barrier by maintaining cyclic guanylate phosphatase and occludin phosphorylation and preventing apoptosis. Finally, high-dose vitamin C can augment antibacterial defense. These protective effects against overwhelming oxidative stress due to ischemia/reperfusion, sepsis or burn seems to mitigate organ injury and dysfunction, and promote recovery after cardiac revascularization and in critically ill patients, in the latter partially in combination with other antioxidants. Of note, several questions remain to be solved, including optimal dose, timing and combination of vitamin C with other antioxidants. The combination obviously offers a synergistic effect and seems reasonable during sustained critical illness. High-dose vitamin C, however, provides a cheap, strong and multifaceted antioxidant, especially robust for resuscitation of the circulation. Vitamin C given as early as possible after the injurious event, or before if feasible, seems most effective. The latter could be considered at the start of cardiac surgery, organ transplant or major gastrointestinal surgery. Preoperative supplementation should consider the inhibiting effect of vitamin C on ischemic preconditioning. In critically ill patients, future research should focus on the use of short-term high-dose intravenous vitamin C as a resuscitation drug, to intervene as early as possible in the oxidant cascade in order to optimize macrocirculation and microcirculation and limit cellular injury.
Vopr Onkol. 1989;35(4):436-41.
[The role of ascorbic acid in the combined preoperative preparation of cancer patients].
[Article in Russian]
Gorozhanskaia EG, Gromova EG, Sviridova SP.
Urine and blood levels of ascorbic acid (AA) were measured in healthy subjects (40), cases of cancer of the lung (74), stomach (32) and esophagus (12). AA levels were decreased in cancer patients, particularly, in those with gastric and esophageal tumors. A correlation between the decrease of AA level and the increase in blood concentrations of malonic and pyruvic acids was established. Administration of 1.5 g AA for 7 days was followed by blood-AA level returning practically to normal matched by decrease in lactate and pyruvate concentrations. Also, a correlation between postoperative complication frequency and AA deficit was shown. Correction of AA level was found to be an effective means of postoperative complication prevention.
Can J Cardiol. 2014 Jan;30(1):96-101. doi: 10.1016/j.cjca.2013.08.018.
The effect of intravenous vitamin C infusion on periprocedural myocardial injury for patients undergoing elective percutaneous coronary intervention.
Wang ZJ1, Hu WK1, Liu YY1, Shi DM1, Cheng WJ1, Guo YH1, Yang Q1, Zhao YX2, Zhou YJ1.
This small study has determined the effect of vitamin C on myocardial reperfusion in patients undergoing elective percutaneous coronary intervention (PCI). This study was to explore whether antioxidant vitamin C infusion before the procedure is able to affect the incidence of periprocedural myocardial injury (PMI) in patients undergoing PCI.
In this prospective single-centre randomized study, 532 patients were randomized into 2 groups: the vitamin C group, which received a 3-g vitamin C infusion within 6 hours before PCI, and a control group, which received normal saline. The primary end point was the troponin I-defined PMI, and the second end point was the creatine kinase (CK)-MB-defined PMI. Separate analyses using both end points were performed. PMI was defined as an elevation of cardiac biomarker values (CK-MB or troponin I) > 5 times the upper limit of normal (ULN), alone or associated with chest pain or ST-segment or T-wave changes.
After PCI, the incidence of PMI was reduced, whether defined by troponin or by CK-MB, compared with the control group (troponin I, 10.9% vs 18.4%; P = 0.016; CK-MB, 4.2% vs 8.6%; P = 0.035). Logistic multivariate analysis showed that preprocedure use of vitamin C is an independent predictor of PMI either defined by troponin I (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.97; P = 0.037) or by CK-MB (OR, 0.37; 95% CI, 0.14-0.99; P = 0.048).
In patients undergoing elective PCI, preprocedure intravenous treatment with vitamin C is associated with less myocardial injury.
Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Injury. 2011 Jan;42(1):78-82. doi: 10.1016/j.injury.2010.01.104. Epub 2010 Feb 10.
High-dose antioxidant administration is associated with a reduction in post-injury complications in critically ill trauma patients.
Giladi AM1, Dossett LA, Fleming SB, Abumrad NN, Cotton BA.
We recently demonstrated a high-dose antioxidant (AO) protocol was associated with reduction in mortality. The purpose of this study was to evaluate the impact of AO on organ dysfunction and infectious complications following injury.
PATIENTS AND METHODS:
High-dose AO protocol: ascorbic acid 1000 mg q 8 h, alpha-tocopherol 1000 IU q 8 h, and selenium 200 mcg qd for 7-day course. Retrospective cohort study evaluating all patients admitted after protocol implementation (AO+), October 1, 2005 to September 30, 2006. Comparison cohort (AO-): all patients admitted in the year prior to implementation, October 1, 2004 to September 30, 2005.
2272 patients included in the AO+ group, 2022 patients in the AO- group. Demographics and injury severity were similar. Abdominal compartment syndrome (ACS) (2.9% vs. 0.7%, <0.001), surgical site infections (2.7% vs. 1.3%, p=0.002), pulmonary failure (27.6% vs. 17.4%, p<0.001), and ventilator-dependent respiratory failure (10.8% vs. 7.1%, p<0.001) were significantly less in the AO+ group. Multivariate regression showed 53% odds reduction in abdominal wall complications and 38% odds reduction in respiratory failure in the AO+ group.
Implementation of a high-dose AO protocol was associated with a reduction in respiratory failure and ventilator-dependence. In addition, AO were associated with a marked decrease in abdominal wall complications, including ACS and surgical site infections.
2010 Elsevier Ltd. All rights reserved.
Ann Clin Biochem. 1986 Sep;23 ( Pt 5):566-70.
Changes in plasma and buffy layer vitamin C concentrations following major surgery: what do they reflect?
Schorah CJ, Habibzadeh N, Hancock M, King RF.
Plasma and buffy layer vitamin C concentrations have been measured in 19 patients before and following major surgery, and falls of 36% and 43% respectively were recorded on the first post-operative day. However, the change in the buffy layer could not be accounted for by a change in the concentration of vitamin C in platelets, mononuclear cells or polymorphonuclear leucocytes, the cell types which form the buffy layer. The buffy layer change could be explained by a post-surgical increase in the number of polymorphonuclear leucocytes which, when the buffy layer vitamin C is expressed per 10(8) white cells, dilutes the platelet and mononuclear cell contribution to the buffy layer vitamin C concentration. The fall in buffy layer vitamin C does not, therefore, reflect any increased demand for white cell vitamin C in the immediate post-operative period, although the decrease in plasma vitamin C could imply some increased utilisation or redistribution of the non-cellular compartment.
Nutrition. 2011 Apr;27(4):435-9. doi: 10.1016/j.nut.2010.02.015. Epub 2010 Jul 1.
Vitamin C supplementation in patients receiving peripheral parenteral nutrition after gastrointestinal surgery.
Yamazaki E1, Horikawa M, Fukushima R.
We investigated an adequate vitamin C dose during peripheral parenteral nutrition therapy in patients after gastrointestinal surgery by measuring blood concentrations and urine excretions of vitamin C. We also sought to identify the effects of vitamin C on the oxidative status.
In a randomized trial, 2 d after undergoing gastrointestinal surgery, 16 patients started to receive a 5-d continuous intravenous infusion of vitamin C, either 100 or 500 mg/d. Blood concentrations of vitamin C and inflammatory and immunologic parameters were measured preoperatively, the day after surgery, and 3 and 5 d after starting administration of vitamin C (day 3 and day 5). Also, excretions of vitamin C and oxidative stress markers in 24-h, cumulative urine samples, collected and stored under light protection at 0°C, were measured on day 3 and day 5.
Mean blood vitamin C concentration decreased markedly after surgery. The concentration returned to normal on day 3 and on day 5 in the 500-mg group and only on day 5 in the 100-mg group. Concentrations differed significantly between the groups on day 3 and on day 5 (P < 0.001 for both days). Urinary vitamin C excretion was above normal on both days in the 500-mg group, but it never reached normal in the 100-mg group (P < 0.001 for both days). Urinary excretion of 8-isoprostane, a marker of oxidative stress, was significantly lower in the 500-mg than in the 100-mg group on day 3 (P = 0.002).
Vitamin C dose of 500 mg/d, not 100 mg/d, is adequate for patients undergoing gastrointestinal surgery and receiving peripheral parenteral nutrition therapy. Vitamin C may decrease postsurgical oxidative stress.
Copyright © 2011 Elsevier Inc. All rights reserved.