Karin Amrein highlights the importance of bone health in ICU. Karin asks – do fractures matter? If the presentation is a hip fracture for elderly patients, then the answer is obviously, yes! However, Karin will describe why this answer should be a resounding yes for all patients who are admitted to the ICU. Critical illness affects bone. It is not a stretch to conceptualise this. However, Karin wants to impress on you that bone affects critical illness also! Bone is an endocrine organ, the largest endocrine organ. Fragility fractures are associated with substantially increased mortality and morbidity. One year post hip fracture, 50% of the patients are either dead or in a nursing home. Prevention is crucial! After an ICU stay, patients have a largely elevated risk of fractures – up to 65%. However, this risk factor is not recognised in the literature. If you survive critical illness and get home, you have done well. If you then sustain a fracture, you are almost back to square one! Karin attempts to explain this association. The ICU population is getting older, and the very nature of an ICU admission means they are predominantly sedentary – that much is true. However, there is likely more factors at play. Inflammation, endocrine alterations, increased osteoclastic activity, hypercatabolism leading to muscle breakdown (and in turn bone breakdown), malnutrition and drugs are all likely implicated in the increased risk. Karin takes you through each factor in turn in detail. So, what can be done about the increased risk of fractures in ICU patients post discharge. Addressing each factor in turn is difficult, however Karin shows some viable options to consider in this patient population. Karin demonstrates how poor bone health, leading to fractures, produces poor outcomes. In turn, she discusses how treating the bone health, and reducing the fracture rate, leads to improved morbidity and mortality! Karin concludes with some recommendations for ICU patients providing some tangible and practical takeaways. For more like this, head to our podcast page. #CodaPodcast

1. BONE
AFTER ICU
KARIN AMREIN
MEDICAL UNIVERSITY GRAZ

3. DO FRACTURES MATTER?
HIP
UPPER ARM

4. Photo: by permission ©Alex Rotas, www.alexrotasphotography.co.uk

5. CRITICAL ILLNESS
AFFECTS
BONE

6. BONE
AFFECTS
CRITICAL ILLNESS

7. FRAGILITY FRACTURES
• ARE ASSOCIATED WITH
–INCREASED MORBIDITY
–INCREASED MORTALITY
Pasco 2005, Edwards 2009, Papaioannou 2010

8. WORST CASE
HIP FRACTURE
• One year after
–Institutionalization ca. 30%
–Death ca. 20%
Pasco 2005, Edwards 2009, Papaioannou 2010

9. 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

10. Orford CCM 2011

11. FRACTURES
4 YEARS AFTER ICU?
• 14% of female and
• 10% of male survivors
Orford CCM 2011

12. IS THIS A PROBLEM?
VERY LIKELY

13. ALTERED BONE TURNOVER
• ELDERLY POPULATION!
• IMMOBILIZATION
Photo: by permission ©Alex Rotas, www.alexrotasphotography.co.uk

14. ALTERED BONE
TURNOVER
• INFLAMMATION
• MULTIPLE ENDOCRINE ALTERATIONS
• HYPERCATABOLISM INCLUDING MUSCLE
WASTING
• MALNUTRITION
• DRUGS

15. IMMOBILIZATION
• -> BONE LOSS
• MECHANOSTAT
Rittweger J 2005 LTBR study; Gaudio A 2010

16. 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

17. MULTIPLE ENDOCRINE
ALTERATIONS
• HYPERCORTISOLISM
• HYPOGONADISM
• HYPOSOMATOTROPISM
• SECONDARY HYPOTHYROIDISM
• ALTERATIONS IN CALCIUM-PHOSPHATE
METABOLISM AND PARATHYROID
HORMONE SECRETION
Vanhorebeek 2006, Kelly 2011

18. MEDICATION
• GLUCOCORTICOIDS
• PROTON PUMP INHIBITORS
• LOOP DIURETICS
• CATECHOLAMINES
• …

19. WHAT CAN WE DO
• TARGET
– IMMOBILIZATION
– VITAMIN D DEFICIENCY
–DRUGS THAT AFFECT BONE
–EARLY IDENTIFICATION OF PATIENTS AT RISK
– BISPHOSPHONATES??
– PROPANOLOL??

20. PROPANOLOL
• UNSELECTIVE ß-BLOCKER
• ATTENUATES BONE LOSS IN 1ST YEAR
FOLLOWING SEVERE BURNS IN
CHILDREN
• REDUCED HYPERCATABOLISM!?
Herndon 2012

21. 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

22. BISPHOSPHONATES & MORTALITY?
Lyles NEJM 2007

23. WHY?

24. LESS PNEUMONIA & ARRHYTHMIA
Colon-Emeric JBMR 2010

25. BISPHOSPHONATE BEFORE ICU!?!
Lee P
JCEM 2016

26. BISPHOSPHONATE VOR ICU!?!
Lee P JCEM 2016

27. BISPHOSPHONATES
BEFORE ICU!?!
Lee P JCEM 2016

28. RECOMMENDATIONS
DURING ICU
–ASSESS AND TREAT VITAMIN D AND
POSSIBLY CALCIUM DEFICIENCY
–WEANING/MOBILIZATION AS SOON AS
POSSIBLE
–REASSESS DRUGS LIKE PPI, STEROIDS…

29. RECOMMENDATIONS
AFTER ICU
–ASSESS AND TREAT RISK FOR FALLS
(PHYSIOTHERAPY, FAMILY, PHYSICIAN,
RELATIVES)
–IDENTIFY OSTEOPOROSIS (FRACTURE
HISTORY, DUAL X-RAY
ABSORPTIOMETRY)

30. RECOMMENDATIONS
AFTER ICU
–ASSESS AND TREAT VITAMIN D
DEFICIENCY
–ASSESS CALCIUM INTAKE
–REASSESS DRUGS LIKE PPI, STEROIDS…

31. CONCLUSIONS
• LIMITED DATA!
• FRACTURES POST ICU = LONG-TERM
SEQUELAE
• SOME CONTRIBUTORS CAN BE MODIFIED
• BISPHOSPHONATES FOR MORTALITY
REDUCTION?

32. THANK
YOU
Photo: by permission ©Alex Rotas,
www.alexrotasphotography.co.uk