Hydroxocobalamin in Septic Shock Management – Should It Be Introduced Sooner?
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Publication Date
4-29-2026
Keywords
oregon, psvmc, psvmc gme, psvmc oaa
Disciplines
Medical Education
Abstract
Introduction: Treating sepsis involves timely antibiotics, adequate fluid resuscitation, and vasopressor support if shock develops. Plasma concentrations of nitric oxide and hydrogen sulfides are elevated in early sepsis, contributing to vasoplegia,1 a pathology that isn’t addressed by vasopressors. High-dose hydroxocobalamin (vitamin B12) does, and therefore, has long been explored as a potential adjunct to vasopressors, though no consensus or official guidelines for its use have been published. Case Report: A 26-year-old man who was diagnosed with acute myeloid leukemia a few months prior presented to the emergency room for fever, weakness, and emesis. He was found to be profoundly hypotensive and was treated with aggressive fluid resuscitation and broad-spectrum antibiotics. His hemodynamics continued to deteriorate, requiring initiation of norepinephrine, vasopressin, and stress-dose hydrocortisone. Despite this, his mean arterial pressure continued to drop, and epinephrine and phenylephrine were added, with fleeting benefits. Ultimately, 5 g of hydroxocobalamin was administered intravenously. Within a few hours, vasopressor doses were able to be reduced significantly, and he was stable enough for abdominal imaging, which showed a perforated sigmoid colon abscess. Surgical intervention was deferred due to the extremely high risk of morbidity and death due to profound pancytopenia and the severity of septic shock. Within 15 hours, his shock improved with down titration of all vasopressors and normalization of lactate levels. He was transferred out of the ICU 21 hours after hydroxocobalamin administration and discharged home a week later Discussion: High-dose hydroxocobalamin prevents nitric oxide and hydrogen sulfide formation, which reduces capillary leak and ultimately improves mean arterial pressure3 . In our profoundly vasoplegic patient, this intervention rapidly restored his hemodynamic status and almost immediately turned around a clinical outcome that most likely would have resulted in death. We suspect the patient’s young age and low burden of comorbidities contributed to this success and suggest that a trial of hydroxocobalamin may be warranted in similar cases. Hydroxocobalamin is often only used when patients fail to respond to vasopressors, though a randomized controlled trial showed administration reduced the dose of vasopressor administered2 . More multicentered, randomized controlled trials and further guidelines are needed to determine when hydroxocobalamin should be used during septic shock management to maximize clinical utility and outcomes.
Specialty/Research Institute
Graduate Medical Education
Specialty/Research Institute
Internal Medicine
