Avaliação de alterações hormonais em pacientes críticos

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Secreção de aldosterona em pacientes com choque séptico : estudo prospectivo

Objective: To assess serum levels of the main factors that regulate the activation of the zona glomerulosa and aldosterone production in patients with septic shock, as well as their response to a high-dose (250 μg) adrenocorticotropic hormone (ACTH) stimulation test. Subjects and methods: In 27 patients with septic shock, baseline levels of aldosterone, cortisol, ACTH, renin, sodium, potassium, and lactate were measured, followed by a cortrosyn test. Results: Renin correlated with baseline aldosterone and its variation after cortrosyn stimulation. Baseline cortisol and its variation did not correlate with ACTH. Only three patients had concomitant dysfunction of aldosterone and cortisol secretion. Conclusions: Activation of the zona glomerulosa and zona fasciculata are independent. Aldosterone secretion is dependent on the integrity of the renin-angiotensin-aldosterone system, whereas cortisol secretion does not appear to depend predominantly on the hypothalamic-pituitaryadrenal axis. These results suggest that activation of the adrenal gland in critically ill patients occurs by multiple mechanisms.Objetivo: Avaliar os níveis séricos dos principais fatores que regulam a ativação da zona glomerulosa e a produção de aldosterona em pacientes com choque séptico, assim como sua resposta ao teste de cortrosina em alta dose (250 μg). Sujeitos e métodos: Em 27 portadores de choque séptico, foram aferidos níveis basais de aldosterona, cortisol, ACTH, renina, sódio, potássio e lactato, bem como realizado teste de cortrosina. Resultados: Renina se correlacionou com níveis basais de aldosterona e sua variação após teste de cortrosina. Cortisol basal e sua variação não se correlacionaram com ACTH. Apenas três pacientes apresentaram disfunção concomitante da secreção de aldosterona e cortisol. Conclusões: Ativação das zonas fasciculada e glomerulosa são independentes. Secreção de aldosterona é dependente da integridade do sistema renina-angiotensina-aldosterona, enquanto secreção de cortisol não parece predominantemente dependente do eixo hipotálamo-hipófise-adrenal. Esses resultados sugerem que a ativação da adrenal em pacientes críticos ocorre por múltiplos mecanismos

Vitamin D deficiency is independently associated with mortality among critically ill patients

OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels ;12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients

Contrasting effects of preexisting hyperglycemia and higher body size on hospital mortality in critically ill patients: a prospective cohort study

Background: Obesity and diabetes mellitus are well-defined risk factors for cardiovascular mortality. The impact of antecedent hyperglycemia and body size on mortality in critical ill patients in intensive care units (ICUs) may vary across their range of values. Therefore, we prospectively analyzed the relationship between in-hospital mortality and preexisting hyperglycemia and body size in critically ill ICU patients to understand how mortality varied among normal, overweight, and obese patients and those with low, intermediate, and high glycated hemoglobin (HbA1c) levels. Methods: Medical history, weight, height, physiologic variables, and HbA1c were obtained during the first 24 h for patients who were consecutively admitted to the high complexity ICU of Hospital de Clínicas de Porto Alegre, Brazil, from April to August 2011. The relationships between mortality and obesity and antecedent hyperglycemia were prospectively analyzed by cubic spline analysis and a Cox proportional hazards model. Results: The study comprised 199 patients. The overall hospital mortality rate was 43.2% during a median 16 (8–28) days of follow-up. There was a progressive risk of in-hospital mortality with higher HbA1c levels, with the relationship becoming significant at HbA1c >9.3% compared with lower levels (hazard ratio 1.74; 95% confidence interval with Bonferroni correction 1.49–2.80). In contrast, mean body mass index (BMI) was higher in survivors than in nonsurvivors (27.2 kg/m2 ± 7.3 vs. 24.7 kg/m2 ± 5.0 P = 0.031, respectively). Cubic spline analysis showed that these relationships differed nonlinearly through the spectrum of BMI values. In a Cox proportional hazards model adjusted for Acute Physiology and Chronic Health Evaluation II score and HbA1c, the risk of in-hospital mortality progressively decreased with increasing BMI (BMI <20 vs. 20–23.9 kg/m2, P = 0.032; BMI <20 vs. 24–34.9 kg/m2, P = 0.010; BMI <20 vs. ≥35 kg/m2, P = 0.032). Conclusions: Our findings suggest that significant hyperglycemia prior to ICU admission is a risk factor for in-hospital mortality. Conversely, increasing BMI may confer an advantageous effect against mortality in critical illness independently of previous glycemic control

Nutritional therapy and outcomes in underweight critically ill patients

Background & aims: Critically ill patients with body mass index (BMI) < 20 kg/m2 have worse outcomes than normal/overweight patients possibly because underweight is a marker of malnutrition. To assess the effects of nutrition therapy in this population during the first week of an ICU stay. Methods: Prospective, 2-centre, observational study. Nutritional evaluations were performed between days 2 and 3 (first) and between days 5 and 7 (second) of ICU admission. In the first evaluation, patients were divided into non-fed (without nutritional support) and early-fed (those already receiving nutritional support) groups. In the second evaluation, patients were divided according to caloric intake (≥or<20 kcal/kg) and protein intake (≥or<1.3 g of protein/kg). Results: Of the 4236 patients screened and 342 were included in the cohort. Mortality was 58.5% (median 21 [11–38.25] days of follow-up). Unadjusted patient survival was worse in the non-fed group than in the early-fed group (HR 1.66; 95%CI, 1.18 to 2.32). There was no difference in mortality between groups after adjusting for the SOFA score on the day of the evaluation. At the second evaluation, unadjusted analysis showed better in-hospital survival in patients with higher caloric (HR0.58; 95%CI, 0.40 to 0.86) and protein intake (HR0.59; 95%CI, 0.42 to 0.82); there was no association between mortality and caloric or protein intake after adjusting for the SOFA score on the day of the evaluation. Conclusion: Nutritional therapy in the first week of ICU stay did not affect vital outcome after adjusting for the SOFA score on the day of the evaluation in underweight critically ill patients