Bone after ICU
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BONE AFTER ICU KARIN AMREIN MEDICAL UNIVERSITY GRAZ
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Transcript of Bone after ICU
BONE AFTER ICU
KARIN AMREINMEDICAL UNIVERSITY GRAZ
DO FRACTURES MATTER?
HIP
UPPER ARM
Photo: by permission ©Alex Rotas, www.alexrotasphotography.co.uk
CRITICAL ILLNESS AFFECTS
BONE
BONE AFFECTS
CRITICAL ILLNESS
FRAGILITY FRACTURES
• ARE ASSOCIATED WITH –INCREASED MORBIDITY–INCREASED MORTALITY
Pasco 2005, Edwards 2009, Papaioannou 2010
WORST CASEHIP FRACTURE
• One year after–Institutionalization ca. 30%–Death ca. 20%
Pasco 2005, Edwards 2009, Papaioannou 2010
FRACTURES AFTER ICU?
• AUSTRALIA, FOLLOW UP 4 YEARS• ICU SURVIVORS VENTILATED > 48 HRS• INDICENT FRACTURES (FX) WERE
COMPARED TO THE GEELONG OSTEOPOROSIS STUDY RETROSPECTIVELY
Orford CCM 2011
Orford CCM 2011
FRACTURES 4 YEARS AFTER ICU?
• 14% of female and • 10% of male survivors
Orford CCM 2011
IS THIS A PROBLEM?VERY LIKELY
ALTERED BONE TURNOVER• ELDERLY POPULATION!• IMMOBILIZATION
Photo: by permission ©Alex Rotas, www.alexrotasphotography.co.uk
ALTERED BONE TURNOVER
• INFLAMMATION• MULTIPLE ENDOCRINE ALTERATIONS• HYPERCATABOLISM INCLUDING MUSCLE
WASTING• MALNUTRITION• DRUGS
IMMOBILIZATION
• -> BONE LOSS • MECHANOSTAT
Rittweger J 2005 LTBR study; Gaudio A 2010
INFLAMMATION• TNF-Α AND IL-6 ARE HIGH IN ICU• EXTREME LEVELS DURING SEPSIS
(-> OSTEOCLASTOGENESIS)• CORRELATION BETWEEN LEVELS
WITH RATE OF BONE LOSS
Van den Berghe 2003, Ding 2008
MULTIPLE ENDOCRINE ALTERATIONS
• HYPERCORTISOLISM• HYPOGONADISM• HYPOSOMATOTROPISM• SECONDARY HYPOTHYROIDISM• ALTERATIONS IN CALCIUM-PHOSPHATE
METABOLISM AND PARATHYROID HORMONE SECRETION
Vanhorebeek 2006, Kelly 2011
MEDICATION
• GLUCOCORTICOIDS• PROTON PUMP INHIBITORS• LOOP DIURETICS• CATECHOLAMINES • …
WHAT CAN WE DO• TARGET
– IMMOBILIZATION – VITAMIN D DEFICIENCY–DRUGS THAT AFFECT BONE–EARLY IDENTIFICATION OF PATIENTS AT RISK– BISPHOSPHONATES??– PROPANOLOL??
PROPANOLOL• UNSELECTIVE ß-BLOCKER• ATTENUATES BONE LOSS IN 1ST YEAR
FOLLOWING SEVERE BURNS IN CHILDREN
• REDUCED HYPERCATABOLISM!?
Herndon 2012
BISPHOSPHONATES• “CLASSIC OSTEOPOROSIS DRUG”, VERY
LONG HALF LIFE• INHIBIT BONE RESORPTION • CONTRAINDICATIONS ?:
– HYPOCALCEMIA!!– RENAL IMPAIRMENT (NOT GFR < 30)– ATRIAL FIBRILLATION
Nierman 2000, Klein 2005, Via 2012
BISPHOSPHONATES & MORTALITY?
Lyles NEJM 2007
WHY?
LESS PNEUMONIA & ARRHYTHMIA
Colon-Emeric JBMR 2010
BISPHOSPHONATE BEFORE ICU!?!
Lee P JCEM 2016
BISPHOSPHONATE VOR ICU!?!
Lee P JCEM 2016
BISPHOSPHONATESBEFORE ICU!?!
Lee P JCEM 2016
RECOMMENDATIONSDURING ICU
–ASSESS AND TREAT VITAMIN D AND POSSIBLY CALCIUM DEFICIENCY
–WEANING/MOBILIZATION AS SOON AS POSSIBLE
–REASSESS DRUGS LIKE PPI, STEROIDS…
RECOMMENDATIONSAFTER ICU
–ASSESS AND TREAT RISK FOR FALLS (PHYSIOTHERAPY, FAMILY, PHYSICIAN, RELATIVES)
–IDENTIFY OSTEOPOROSIS (FRACTURE HISTORY, DUAL X-RAY ABSORPTIOMETRY)
RECOMMENDATIONSAFTER ICU
–ASSESS AND TREAT VITAMIN D DEFICIENCY
–ASSESS CALCIUM INTAKE–REASSESS DRUGS LIKE PPI, STEROIDS…
CONCLUSIONS
• LIMITED DATA!• FRACTURES POST ICU = LONG-TERM
SEQUELAE• SOME CONTRIBUTORS CAN BE MODIFIED• BISPHOSPHONATES FOR MORTALITY
REDUCTION?
THANK YOU
Photo: by permission ©Alex Rotas, www.alexrotasphotography.co.uk
