Asymmetrical dimethylarginine (ADMA) in critically ill patients: high plasma ADMA concentration is an independent risk factor of ICU mortality

Van, Nijveldt Rj, Teerlink T, Siroen Mpc, Kuik Dj, Rauwerda Ja

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• Publié par: biomed
• Publié le: 01 janvier 2003
• Nombre de lectures: 3
• Langue: English
• Poids de l'ouvrage: 1 Mo

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Available online http://ccforum.com/supplements/7/S2
Critical Care Volume 7 Suppl 2, 2003
23rd International Symposium on Intensive Care and Emergency
Medicine
Brussels, Belgium, 18–21 March 2003
Published online: 3 March 2003
This article is online at http://ccforum.com/supplements/7/S2
© 2003 BioMed Central Ltd (Print ISSN 1364-8535; Online ISSN 1466-609X)
P1 Endocrine dysfunction in the immediate period following traumatic brain injury
I Dimopoulou, S Tsagarakis, G Assithianakis, M Christoforaki, M Theodorakopoulou, A Kouyialis, S Korfias, N Thalassinos,
C Roussos
Department of Critical Care Medicine and Department of Endocrinology, Evangelismos Hospital, Athens, Greece
Critical Care 2003, 7(Suppl 2):P001 (DOI 10.1186/cc1890)
Studies on head injury-induced pituitary dysfunction are limited in serum fT4 level was associated with a normal or low TSH.
Hypogonumber and conflicting results have been reported. To further clarify nadism was considered when T (males) or E2 (women) were below
this issue, 29 consecutive patients (24 males), with severe (n = 21) the local reference ranges, in the presence of normal PRL levels.
or moderate (n=8) head trauma, having a mean age of Severe or partial GH deficiencies were defined as a peak GH
37±17years were investigated in the immediate post-trauma below 3 µg/l or between 3 and 5 µg/l, respectively, after stimulation
period. All patients required mechanical ventilatory support for with GHRH. Twenty-one subnormal responses were found in 15 of
8–55 days and were enrolled in the study within a few days before the 29patients (52%) tested; seven (24%) had hypogonadism,
ICU discharge. Basal hormonal assessment included measurement seven (24%) had cortisol hyporesponsiveness, five (17%) had
of cortisol, corticotropin, free thyroxine (fT4), thyrotropin (TSH), hypothyroidism, and two patients (7%) had partial GH deficiency.
testosterone (T) in men, estradiol (E2) in women, prolactin (PRL),
and growth hormone (GH). Cortisol and GH levels were measured These preliminary results suggest that a certain degree of
hypoalso after stimulation with 100 µg human corticotropin releasing pituitarism occurs in more than 50% of patients with moderate or
hormone (hCRH) and 100 µg growth hormone releasing hormone severe head injury in the immediate post-trauma period, with cortisol
(GHRH), respectively. Cortisol hyporesponsiveness was consid- hyporesponsiveness and hypogonadism being most common. Further
ered when peak cortisol concentration was less than 20 µg/dl fol- studies are required to elucidate the pathogenesis of these
abnorlowing hCRH. TSH deficiency was diagnosed when a subnormal malities and to investigate whether they affect long-term morbidity.
P2 Cortisol reserve in head trauma victims: evaluation with the low-dose (1 µg) corticotropin (ACTH) stimulation test
I Dimopoulou, A Kouyialis, S Tsagarakis, M Theodorakopoulou, G Assithianakis, M Christoforaki, N Thalassinos, C Roussos
Department of Critical Care Medicine and Department of Endocrinology, Evangelismos Hospital, Athens, Greece
Critical Care 2003, 7(Suppl 2):P002 (DOI 10.1186/cc1891)
To investigate cortisol reserve in head trauma, 35consecutive 49±27pg/ml, 19.7±5.5 µg/dl and 23.6±6.7 µg/dl, respectively.
patients (30 men) with a mean age of 36±16 years were studied Six of the 35 patients (17%) failed the LDST. Nonresponders were
5–60 days after physical injury. Patients were enrolled in the study similar to responders with regard to age, gender, and severity of
within a few days before ICU discharge. First, a morning blood head injury. However, nonresponders more frequently required
sample was obtained to measure baseline cortisol, and ACTH vasopressors (6/6 vs 14/29, P=0.02) and for a longer time
interplasma levels. Subsequently, 1 µg synthetic ACTH was injected val (median, 293 hours vs 24 hours, P=0.01) to maintain
haemointravenously and, 30 min later, a second blood sample was drawn dynamic stability compared with responders to the LDST.
to determine stimulated plasma cortisol. Patients having stimulated
cortisol levels below 18 µg/dl were defined as nonresponders to In conclusion, adrenal cortisol secretion following dynamic
stimulathe low-dose stimulation test (LDST). Mean (±SD) values for tion is deficient in a subset of head injury patients; this condition is
ACTH, baseline, and stimulated cortisol concentrations were associated with vasopressor dependency.
P3 Steroid hormone synthesis is impaired in patients with severe sepsis
M Angstwurm, A Rashidi Kia, J Schopohl, R Gaertner
Medical Intensive Care Unit, Medizinische Klinik, Ziemssenstraße 1, 80336 Munich, Germany
Critical Care 2003, 7(Suppl 2):P003 (DOI 10.1186/cc1892)
In patients with severe illness, adrenal insufficiency is often sus- We analyzed the synthesis of different steroid hormones within
pected and treatment with hydrocortisone has been shown to the adrenal in severely ill patients in a prospective study using
decrease mortality. However, the pathophysiology of an adrenal the established high dose stimulation test with synthetic
failure is only partially understood. cosyntropin. S1Critical Care March 2003 Vol 7 Suppl 2 23rd International Symposium on Intensive Care and Emergency Medicine
Using commercially available essays, the steroid hormones proges- After stimulation with cosyntropin, testosterone, 17β-estradiol and
terone, cortisole, testosterone, dehydroepiandrostenedione (DHEAS) DHEAS remained constant, whereas progesterone increased
and 17β-estradiol were determined before, and 30and 60min (P<0.001) in all groups of patients without significant difference
after stimulation with cosyntropin. Patients were characterized by between groups. In control or cardiogenic patients cosyntropin
scoring systems (APACHE II, SAPS II, MOD score). The underly- stimulation leads to significantly increasing values of cortisol
–12ing admission diagnosis grouped patients in septic, cardiogenic (P=2.15×10 and P=0.04); in patients with sepsis the
shock or control. increase of cortisol (P>0.1) was blunted, however. This decrease
in cortisol stimulation was independent of the use of sedatives or
Sixty-five patients (22 in cardiogenic and 43 in septic shock, five mechanical ventilation. In cardiogenic patients the increase in
cortiand nine women, mean age 58 years, APACHE score of 20) were sol levels after stimulation was similar to control patients (7 µg/dl)
compared with 34 control patients (17 cancer patients, 10 healthy, and was not influenced by increasing dosage of catecholamines; in
four pulmonary emphysema and three other). septic patients the cortisol increase was significantly lower
(P<0.01) with high catecholamines (2 µg/dl) than with low
cateAt baseline, septic and cardiogenic patients showed similar cortisol cholamines (7 µg/dl).
levels (21and 21 µg/dl), higher than control (15 µg/dl, P < 0.05).
Progesterone was increased fourfold (P<0.001) in septic At baseline, patients at the intensive care unit had higher
proges(1.2ng/ml) and cardiogenic shock (1.1ng/ml) compared with terone levels than normal. Septic patients showed diminished
control (0.3ng/ml). Men with sepsis had the highest β-estradiol response to cosyntropin stimulation regarding cortisol levels
levels. Baseline cortisol levels were only slightly higher in intensive despite a normal increase of progesterone. This points to an
care patients compared with control. There were no clear correla- impairment of cortisol synthesis.
tions between steroid hormones and scoring systems or laboratory
signs of infections like CRP, PCT, leukocyte or platelet counts.
P4 Determination of functional states during sepsis-induced activation of the hypothalamic–pituitary–adrenal (HPA) axis
using measurement of ACTH, cortisol, dehydroepiandrosterone-sulfate (DHEAS) and dehydroepiandrosterone (DHEA)
1,2 1 3 1 2 1C Marx , M Wendt , S Petros , L Engelmann , M Weise , G Höffken
1 2 3Internal Medicine I/ Medical ICU, University Hospital Carl Gustav Carus, Fetscherstraße 74, 01307 Dresden; Medical ICU, University of
Leipzig, Germany
Critical Care 2003, 7(Suppl 2):P004 (DOI 10.1186/cc1893)
Introduction Activation of the HPA axis occurs in order to control inflammation or exhaustion and hyperinflammation, respectively:
potentially deleterious effects of systemic inflammation during suppression of inflammation by glucocorticoids or development of
sepsis. Practically, it is difficult to determine different states of HPA relative adrenal insufficiency by adrenal exhaustion resulting in
relaactivation since a differing dynamics and individual risk have to be tive hyperinflammation. IV) Recovery or insufficiency, respectively:
considered. normalisation of cytokine levels and regeneration of the adrenal
driven by normalisation of ACTH. Reconstitution of physiologic
Methods Recently, we examined levels of cortisol, DHEAS, DHEA ACTH-driven regulation or relative adrenal insufficiency with poor
as well as ACTH in 30patients with severe sepsis (15survivors, prognosis, respectively.
15nonsurvivors) and correlated the time course during early and
late sepsis to the clinical course and inflammatory markers [1]. Discussion The HPA axis reflects the individual prognostic risk of
Here, we demonstrate and describe different states of HPA activa- the patient. The clinical course rarely enables the