Hypooncotic Critical Illness and ICU Outcomes Under Anabolic Steroid Therapy Supplementation
CCCF ePoster library. Perk M. Nov 2, 2016; 151001; 119 Disclosure(s): No disclosure
Dr. Masis Perk
Dr. Masis Perk
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Abstract
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Topic: Retrospective or Prospective Cohort Study

HYPOONCOTIC CRITICAL ILLNESS AND ICU OUTCOMES UNDER ANABOLIC STEROID THERAPY SUPPLEMENTATION


Perk, Masis MD, FRCPC ; Berkvens, Laura BScN, RN, CNCC(c)
Colchester East Hants Health Centre  ICU , Truro, Nova Scotia, Canada



Abstract:

Introduction:  A hypooncotic state commonly occurs in  the course of critical illness,. Marked hypoalbuminemia,  administration of crystalloids or other iv therapies contribute to fluid extravasation and retention in a gravity dependent fashion in the lungs & ,pleural cavity, skin & subcutaneous space, abdomen, intestinal wall and extremities.  Lung edema, hydrothorax, diaphragmatic dysfunction, intercostal myopathy, edema overlying the thoraco-abdominal wall & flanks, ascites, ileus, all adversely effect  respiratory mechanics, create weaning difficulty and increase ICU mortality. In practice, such patients are often labelled as 'ARDS', a term regarded as synonymous with 40-60% in-hospital mortality. We avoided using this term in our  ICU sub-population because  a proactive anabolic strategy offered  better outcomes. Instead, we used  Hypooncotic Critical  Illness ( HOCI ) which defines the underlying pathophysiology and associations.

Objectives:  To increase awareness re. the clinical ramifications of hypooncotic critical illness. To draw attention to it's potentially more favourable prognosis than ARDS. To share our early experience and results with ICU attending physicians and nurses re. the proactive management of HOCI including  supplemental anabolic steroid hormone therapy.

Methods:  In the last 3 calendar years,  20 patients ( 10 males, age  65 +/-13, 10 females, age 68 +/- 11 ) admitted to our ICU developed  HOCI along the course of their stay. 11 patients had respiratory, cardiovascular or combined primary causes for admission ( 6 sepsis, 4 pneumonia, 1 aspiration ). 14 patients were medical and 6 patients were post-surgical . 17/20 requried mechanical ventilatory support.  APACHE III score was used for mortality prediction.. Serum albumin levels were measured serially ( normal range 34-50 g/L ).  Bedside echocardiography was used  to exclude heart failure in some cases.  Ultraound-guided thoracentesis was used when necessary.  Male patients with HOCI who had contraindications against androgen therapy were not included (ie. prostate problems, abnormal PSA elevation ) . This was a closely collaborative ( MD, RN driven ) observational study in which anabolic strategy was pre-conceived in  HOCI with a serum albumin levels  < 30 g/L.. Qualifying patients were prospectively administered 1- 2 doses of  100 mg Testosterone enanthate im., 7-10 days apart. 

Results:  Mean APACHE III score on presentation was 58 +/-16. Mean serum albumin level before therapy was 19 +/- 5 g/L . 17/20 patients received mechanical ventilatory support. Total days on ventilator was 298 days. After anabolic steroid therapy, total days on ventilator was 87 days. Despite their  scores of predicted ICU mortality, 14/17 patients were successfully weaned off ventilator  and 17/20 patients were discharged  in good  recovery ( 85 %) . 3/20 patients died after extubation for end of life care ( 15%).

Conclusion: In this single-centre observational prospective cohort  study, patients with HOCI, treated with supplemental anabolic steroid hormone therapy had  lower standardized mortality ratios by comparison to  expected mortality rates.  We conclude  that anabolic activity enhancement may have a  far greater rpositive role in ICU outcomes .  Such therapy is safe for  the intended purpose, widely available and has a low cost impact . Our  study will  hopefully redirect attention to this potentially treatable condition and  help intensive care providers overcome weaning difficulties in both medical and post-surgical HOCI. 


References:

Heunks, LMA et al.: Strategies to optimize respiratory muscle function in ICU. Critical Care. 2016: 20: 103
Pikul J, Sharpe MD : Use of anabolic steroid therapy in the critically ill ICU patients. Critical Care  2003: 7 ( Suppl 2) : 14
Chang DW, DeSanti L: Anticatabolic and anabolic strategies in critical illness: a review.  Shock 1998 : Sep;10 (3): 155-60
Ware LB, Bernard GR : ARDS, Chapter 75, 571-9  in Textbook of Critical Care, 5th ed. 2005, Elsevier-Saunders, PA



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