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The Importance of Bone Health in Intensive Care Units: Karin Amrein
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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
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The Importance of Bone Health in Intensive Care Units: Karin Amrein
- BONE AFTER ICU KARIN AMREIN MEDICAL 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 CASE HIP 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
- BISPHOSPHONATES BEFORE ICU!?! Lee P JCEM 2016
- RECOMMENDATIONS DURING ICU –ASSESS AND TREAT VITAMIN D AND POSSIBLY CALCIUM DEFICIENCY –WEANING/MOBILIZATION AS SOON AS POSSIBLE –REASSESS DRUGS LIKE PPI, STEROIDS…
- RECOMMENDATIONS AFTER ICU –ASSESS AND TREAT RISK FOR FALLS (PHYSIOTHERAPY, FAMILY, PHYSICIAN, RELATIVES) –IDENTIFY OSTEOPOROSIS (FRACTURE HISTORY, DUAL X-RAY ABSORPTIOMETRY)
- RECOMMENDATIONS AFTER 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