Bone Hyperresorption Is Prevalent in Chronically Critically III Patients

doi:10.1378/chest.114.4.1122

Chest

Volume 114, Issue 4, October 1998, Pages 1122-1128

https://doi.org/10.1378/chest.114.4.1122 Get rights and content

Study objective

Chronically critically ill (CCI) patients are primarily elderly people who have survived a life-threatening episode of sepsis but remain profoundly debilitated and ventilator dependent. The objective of this study was to determine the prevalence of bone hyperresorption and parathyroid hormone (PTH)-vitamin D axis abnormalities in these patients.

Design

Prevalence survey.

Setting

Respiratory care step-down unit (RCU) at a tertiary care teaching hospital.

Patients

Forty-nine ventilator-dependent CCI patients transferred from ICUs within the same institution.

Intervention: None

Measurements and results

N-telopeptide (NTx) levels in 24-h urine collections and serum intact PTH, 25-vitamin D, and 1,25-vitamin D levels were measured within 48 h of RCU admission. Patients were hospitalized a median of 30 days before RCU admission. Four patients (9%) had normal NTx and PTH levels. Forty-five patients (92%) had elevated urine NTx levels consistent with bone hyperresorption. Nineteen patients (42% of total patients) had elevated PTH levels consistent with predominant vitamin D deficiency, 4 patients (9%) had suppressed PTH levels consistent with predominant hyperresorption from immobilization, and 22 patients (49%) had normal PTH levels consistent with an overlap of both vitamin D deficiency and immobilization. There were no differences in vitamin D metabolites among these groups.

Conclusions

CCI patients have a high prevalence of bone hyperresorption in which PTH levels may clarify the cause. Further studies will determine the efficacy and cost-effectiveness of routine NTx and PTH screening in these patients and the role of vitamin D and antiresorptive therapies.

Section snippets

MATERIALS AND METHODS

This project was approved by the Mt. Sinai Medical Center's Institutional Review Board.

RESULTS

Prospective data were collected on 71 consecutive patients admitted to the RCU during the 6-month period between March 1, and August 31, 1997. Three of these patients were transferred from other hospitals with incomplete pretransfer data available, five patients were not intubated and were admitted for terminal care, three patients had preexisting permanent tracheotomies prior to hospitalization and were receiving intermittent home ventilation, and one patient with asthma was transferred from

DISCUSSION

On admission to the RCU, 92% of CCI patients had bone hyperresorption due to either vitamin D deficiency and/or immobilization. No demographic variable predicted which pattern of metabolic disorder would be exhibited. Left unrecognized and untreated, these disorders can result in metabolic bone disease.

Although most patients who survive a critical illness remain critically ill in the ICU for only a few days, some patients remain critically ill for weeks to months. As our understanding of

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: Supported by the Catherine and Henry Gaisman Foundation and IVonyx

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Chest

Clinical Investigations in Critical CareBone Hyperresorption Is Prevalent in Chronically Critically III Patients

Study objective

Design

Setting

Patients

Measurements and results

Conclusions

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Mayo Clin Proc

Chest

Mayo Clin Proc

Chest

Chest

Arch Phys Med Rehabil

Am J Med

Clin Chest Med

The chronically critically ill: to save or let die?

Respir Care

Intensive care unit survival of patients with systemic illness

Am Rev Respir Dis

Development of a special care unit for chronically critically ill patients

Heart Lung

Weaning chronically critically ill adults from mechanical ventilatory support: a descriptive study

Am J Crit Care

Patient outcomes for the chronically critically ill: special care unit versus intensive care unit

Nurs Res

The cost-effectiveness of a special care unit to care for the chronically critically ill

J Nurs Adm

Survival experience of chronically critically ill patients

Nurs Res

Prevalence and biologic consequences of vitamin D deficiency in elderly institutionalized subjects

Rev Rhum Engl Ed

Follow-up study of biological parameters in elderly institutionalized patients more than 1 year after discontinuation of calcium-vitamin D supplementation

Rev Rhum Engl Ed

Vitamin D deficiency and osteoporosis: the role of vitamin D deficiency and treatment with vitamin D and analogues in the prevention of osteoporosis-related fractures

Eur J Clin Invest

Measurement of vitamin D and its metabolites (calcidiol and calcitriol) and their clinical significance

Scand J Clin Lab Invest Suppl

Clinical Investigations in Critical Care
Bone Hyperresorption Is Prevalent in Chronically Critically III Patients