Incidence and aetiology of renal phosphate loss in patients with hypophosphatemia in the intensive care unit

Background

Hypophosphatemia is a common finding in patients in the intensive care unit (ICU). Its cause is often poorly understood.

Purpose

The aim of this study was to understand the incidence of renal phosphate loss in ICU-related hypophosphatemia, and to examine the role of phosphaturic hormones in its etiology.

Methods

Plasma phosphate levels were measured on day 1, 3, 5 and 7 in 290 consecutive patients admitted to the ICU. Renal phosphate handling and phosphaturic hormones were studied in a subset of patients with phosphate levels <0.6 mmol/L. Renal phosphate loss was defined as a TmP/gfr < 0.6 mmol/L.

Main Results

Hypophosphatemia developed in 24 % of all patients. This mainly occurred within the first 3 days of stay and in patients with serum creatinine levels <150 μmol/L. Renal phosphate loss was present in 80 % of patients who developed hypophosphatemia, and was not related to serum levels of parathyroid hormone (PTH), PTH-related protein (PTH-rp), fibroblast growth factor 23 (FGF-23), or calcitonin.

Conclusion

Hypophosphatemia in the ICU is commonly associated with renal phosphate loss. It mainly occurs within the first 3 days of admission, in particular in patients with preserved renal function. Renal phosphate loss is not explained by elevated PTH, PTH-rp, FGF-23 or calcitonin levels.     

Treatment of hypophosphatemia in the intensive care unit: a review

Introduction  

Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients.     

Designing drug regimens for special intensive care unit populations

This review is intended to help clinicians design drug regimens for special populations of critically ill patients with extremes of body size, habitus and composition that make drug choice or dosing particularly challenging due to the lack of high-level evidence on which to make wellinformed clinical decisions. The data sources included a literature search of MEDLINE and EMBASE with reviews of reference lists of retrieved articles. Abstracts of original research investigations and review papers were reviewed for their relevance to drug choice or dosing in the following special critically ill populations: patients with more severeforms of bodyweight or height, patients with amputations or missing limbs, pregnant patients, and patients undergoing extracorporeal membrane oxygenation or plasma exchange. Relevant papers were retrieved and evaluated, and their associated reference lists were reviewed for citations that may have been missed through the electronic search strategy. Relevant original research investigations and review papers that could be used to formulate general principles for drug choice or dosing in special populations of critically ill patients were extracted. Randomized studies with clinically relevant endpoints were not available for performing quantitative analyses. Critically ill patients with changes in body size, habitus and composition require special consideration when designing medication regimens, but there is a paucity of literature on which to make drug-specific, high-level evidencebased recommendations. Based on the evidence that is available, general recommendations are provided for drug choice or dosing in special critically ill populations.     

重症监护病房患者低磷血症的发生及对预后的影响

目的 调查重症监护病房(ICU)患者低磷血症的发生情况,研究不同血磷水平对患者预后的影响.方法 观察2010年4月至11月入住盛京医院ICU 147例患者的血磷水平及低磷血症的发生率,比较轻、中、重度血磷水平患者间急性生理学与慢性健康状况评分系统Ⅱ( APACHEⅡ)评分、住ICU时间、主要实验室指标以及病死率的差异;比较生存和死亡患者住ICU期间血磷的变化.建立血磷水平与是否存活患者之间的受试者工作特征曲线(ROC曲线),探讨血磷水平对预测患者预后的意义.结果 77.6％的患者在入住ICU期间出现低磷,轻度21例、中度70例、重度23例,其中63.3％的患者出现中至重度的低磷;显著低磷的患者不仅APACHEⅡ评分(分)较高(轻度18.2±6.0,中度21.4±7.6,重度25.6±8.8,正常18.9±8.8),呼吸机使用时间(d)延长(轻度6.6±5.1,中度11.3±9.5,重度15.7±10.4,正常6.7±5.9),住ICU时间(d)较长(轻度9.7±6.4,中度10.6±8.2,重度18.9±13.1,正常9.9±7.1),而且病死率随之升高(轻度14.3％,中度25.7％,重度39.1％,正常9.1％).ICU患者的总病死率(22.4％)与低磷的程度呈显著负相关(r=-0.225,P=0.01);血磷＜0.40 mmol/L时预测患者存活的敏感性为78.6％,特异性为51.5％,提示预后较差.结论 大部分ICU患者血磷处于相对较低的水平.ICU患者容易合并低磷血症,重度低磷提示ICU患者预后较差.     

Assessment of two hand hygiene regimens for intensive care unit personnel

OBJECTIVE: To compare skin condition and skin microbiology among intensive care unit personnel using one of two randomly assigned hand hygiene regimens: a 2% chlorhexidine gluconate (CHG)-containing traditional antiseptic wash and a waterless handrub containing 61% ethanol with emollients (ALC). DESIGN: Prospective, randomized clinical trial. SETTING: Two critical care units (medical and surgical) in a large, metropolitan academic health center in Manhattan. SUBJECTS: Fifty staff members (physicians, nurses, housekeepers, respiratory therapists) working full time in the intensive care unit. INTERVENTIONS: One of two hand hygiene regimens randomly assigned for four consecutive weeks. MEASUREMENTS AND MAIN RESULTS: The two outcomes were skin condition (measured by two tools: Hand Skin Assessment form and Visual Skin Scaling form) and skin microbiology. Samples were obtained at baseline, on day 1, and at the end of wks 2 and 4. Participants in the ALC group had significant improvements in the Hand Skin Assessment scores at wk 4 (p = 0.04) and in Visual Skin Scaling scores at wks 3 (p = 0.01) and 4 (p = 0.0005). There were no significant differences in numbers of colony-forming units between participants in the CHG or ALC group at any time period. The ALC regimen required significantly less time than the CHG regimen (mean: 12.7 secs and 21.1 secs, respectively; p = 0.000) and resulted in a 50% reduction in material costs. CONCLUSIONS: Changes in hand hygiene practices in acute care settings from the traditional antiseptic wash to use of plain, mild soap and an alcohol-based product should be considered. Further research is needed to examine the association between use of antiseptic products for hand hygiene of staff and reductions in nosocomial infection rates among patients.     

Management of severe and complicated malaria in the intensive care unit

Malaria remains today one of the major health problems in the tropics with increased morbidity and mortality. The most serious complications are caused by Plasmodium falciparum, which, in contrast to the benign malarias, may progress to a life-threatening multi-system disease. Our case concerns a young woman in the 14th week of pregnancy, admitted to the ICU in a coma, with pulmonary oedema, haemolytic anaemia, renal failure and thrombocytopenia as complications of P. falciparum malaria. The case is discussed and possible explanations for the clinical picture and complications of P. falciparum malaria are given in the light of experiences from the literature. Received: 11 November 1998 Accepted: 12 April 1999     

Hyperoxia in the intensive care unit: why more is not always better

PURPOSE OF REVIEW: Hyperoxic inspired gas is essential for patients with hypoxic respiratory failure; it is also suspected, however, as a contributor to the pathogenesis of acute lung injury. Several recent studies in humans, animals, and cell culture have identified mechanisms by which hyperoxia may exert deleterious effects on critically ill patients. This review identifies relevant new findings regarding hyperoxic lung injury in the context of providing guidance for future clinical studies. RECENT FINDINGS: Recent studies have clarified the roles of both receptor-mediated and mitochondrial cell death pathways in experimental hyperoxic lung injury. Studies in animals demonstrate that hyperoxia interacts with mechanical stretch to augment ventilator-induced lung injury. Finally, studies in humans implicate hyperoxia in impairment of host defense responses to infections. SUMMARY: Although hyperoxia has not been conclusively identified as a clinically important cause of lung injury in humans, animal data strongly implicate it. Reports of interaction effects between hyperoxia and both mechanical ventilation and host defense suggest that clinical studies of hyperoxia must take these variables into account. Accumulating data about how hyperoxia initiates cell death provide guidance for development of both biomarkers to identify hyperoxia-induced injury and pharmacological interventions to limit hyperoxia's adverse effects.     

Outcome of severe adult thrombotic microangiopathies in the intensive care unit

Objective Thrombotic microangiopathies, namely thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, are uncommon microvascular occlusive diseases. Despite the dramatic improvement in the outcome by exogenous plasma supply, either through plasma infusion or through plasma exchange, patients frequently require support in the intensive care unit. In the present study, we evaluated the outcome of a large cohort of patients with severe thrombotic microangiopathies.Design A retrospective multicenter study from January 1998 to June 2001.Setting Fourteen French university hospital medical intensive care units.Patients Sixty three adult patients with severe thrombotic microangiopathies.Measurements and results Of the 63 patients, 19 had a clinical presentation of thrombotic thrombocytopenic purpura, 18 had hemolytic uremic syndrome and 26 had combined neurologic and renal failures. Infections were the main etiology associated with thrombotic microangiopathies. The mortality rate was 35%. Of the survivors, all achieved complete remission. Whereas neurologic failure assessed through the Glasgow coma scale was an independent predictor of mortality [HR=0.845 (CI 95%: 0.759–0.940), P=0.002], renal impairment did not appear to be an adverse prognostic factor. The use of plasma exchange was independently associated with survival [HR=0.269 (CI 95%: 0.104–0.691), P=0.006].Conclusions Thrombotic microangiopathies with severe organ dysfunctions leading to hospitalization in the intensive care unit are associated with high mortality. Neurologic impairment appears to be the main adverse prognostic factor correlated to mortality, and the study confirms the importance of plasma exchange in the treatment of high-risk patients.     

Complementary care: Alternatives for the neonatal intensive care unit

This report presents a variety of complementary and alternative medicine (CAM) modalities that may expand the conceptual framework and the evolution of the field of neonatology. This brief overview provides evidence-based support of CAM therapies and suggests areas for future expansions. The National Center of Complementary Medicine (NCCAM) categories of lifestyle and biomechanical therapies guide the discussion. The catalyst for exploring complementary care is a desire to identify and expand the nuturants newborns require, such as intense care. The fundamental philosophy of intense care emphasizes the infant and family and inspires a fresher, clearer vision of relationships. Knowing that infants are amazingly responsive organisms, health care providers are faced with the realization that the environment must be thoughtfully designed. The holistic medical movement has increasingly challenged the health care profession to broaden the definitions of care and maximize the awareness of the mother-infant bond and parent competency. Copyright © 2001 by W.B. Saunders Company     

Leeches in the intensive care unit: nursing care

Leeches have been used in medicine since ancient times. Leeches or Hirudos were used to treat multiple diseases, since the bleeding they induce was related to purification. This practice subsequently fell into disuse until the 1980s when leeches again began to be applied in the treatment of venous congestion and in plastic and reconstructive surgery, especially in the USA and Germany. The use of leeches is not yet widespread in Spain. One of the Spanish hospitals pioneering this practice is the University Hospital Joan XXIII de Tarragona, where leeches are employed in the Maxillofacial Service among patients with microvascularized grafts. The present article describes the therapeutic use of leeches (Hirudo medicinalis), as well as the nursing care and complications in patients undergoing this treatment. The aim is to ensure that this new technique is used with maximal safety and quality.