Zusammenfassung
Akute endokrine Störungen, wie z. B. die thyreotoxische Krise oder primäre Nebennierenrinden(NNR)-Störungen, führen relativ selten zu manifesten Organdysfunktionen und bedürfen daher nur in Einzelfällen einer Therapie auf der Intensivstation. Im Gegensatz dazu sind jedoch Veränderungen der endokrinen und metabolischen Regulation, die als Folge verschiedener extraendokriner Grunderkrankungen bei kritisch kranken Patienten entstehen, auch im Rahmen der postoperativen Betreuung herzchirurgischer Patienten häufig zu beobachten. In den letzten Jahren rücken diese Erkrankungen zunehmend in den Brennpunkt von Wissenschaft und Klinik, da v. a. der Stressdiabetes und das Low-T3-Syndrom als klinisch relevanteste Endokrinopathien kritisch Kranker deren Prognose entscheidend mitbestimmen. Da jedoch metabolische Veränderungen im Rahmen schwerer Erkrankungen oder Trauma, z. B. das Low-T3-Syndrom, auch als sinnvolle Adaptation an kritische Erkrankungen zur Begrenzung des Hyperkatabolismus gewertet werden können, stellt sich immer die Frage nach der Sinnhaftigkeit einer therapeutischen Intervention. Vor dem Hintergrund der Komplexität dieser Thematik werden im Folgenden v. a. der Stressdiabetes und das Low-T3-Phänomen unter Berücksichtigung der aktuellen Studienlage und verfügbarer Leitlinien diskutiert.
Abstract
Critical illness is characterized by important endocrine and metabolic changes with increased lipolysis, proteolysis and gluconeogenesis, which redirect energy consumption toward those processes that mediate acute survival. The initial „adaptive“ neuroendocrine response to critical illness consists primarily of activated anterior pituitary function. Hyperglycemia as well as low thyroid hormone levels can frequently be observed and have been identified as independent predictors of mortality; however, the precise pathophysiological role of the low T3 syndrome is not well understood and the common belief is in favor of an adaptive mechanism to preserve energy. Therefore, an endocrine intervention to improve outcome is questionable and the debate about optimal blood sugar levels on the intensive care unit (ICU) continue to highlight only two of many controversies that remain in this area. Therefore, this review addresses the most commonly observed endocrine dysfunctions after cardiothoracic surgery including diabetes, thyroid abnormalities as well as the issues of corticosteroid replacement and pharmacological applications in this setting.
This is a preview of subscription content, log in via an institution to check access.
Literatur
Kienitz T, Mönig H (2014) Endocrine changes in critically ill patients. Dtsch Med Wochenschr 139(31–32):1565–1567 (Aug)
Boonen E, Van den Berghe G (2014) Endocrine responses to critical illness: novel insights and therapeutic implications. J Clin Endocrinol Metab 99(5):1569–1582 (May)
Umpierrez GE, Smiley D (2013) Pathophysiology of inhospital hyperglycemia. In: Holzinger U (Hrsg) Glucose management and insulin treatment in intensive care. ch 1. Uni-Med Science, Bremen
van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive insulin therapy in critically ill patients. N Engl J Med 345(19):1359–1367
Green DM, O’Phelan KH, Bassin SL, Chang CW, Stern TS, Asai SM (2010) Intensive versus conventional insulin therapy in critically ill neurologic patients. Neurocrit Care 13(3):299–306 (Dec)
Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, Syed SJ, Giridhar HR, Rishu AH, Al-Daker MO, Kahoul SH, Britts RJ, Sakkijha MH (2008) Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med 36(12):3190–3197 (Dec)
Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354(5):449–461 (Feb)
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360(13):1283–1297
NICE-SUGAR Study Investigators, Finfer S, Liu B, Chittock DR, Norton R, Myburgh JA, McArthur C, Mitchell I, Foster D, Dhingra V, Henderson WR, Ronco JJ, Bellomo R, Cook D, McDonald E, Dodek P, Hébert PC, Heyland DK, Robinson BG (2012) Hypoglycemia and risk of death in critically ill patients. N Engl J Med 367(12):1108–1118
Bagshaw SM, Bellomo R, Jacka MJ et al (2009) The impact of early hypoglycemia and blood glucose variability on outcome in critical illness. Crit Care 13(3):R9110
Egi M, Bellomo R, Stachowski E et al (2010) Hypoglycemia and outcome in critically ill patients. Mayo Clin Proc 85(3):217–224
Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Loeffler M, German Competence Network Sepsis (SepNet) (2008) Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358(2):125–139
Preiser JC, Devos P, Ruiz-Santana S, Mélot C, Annane D, Groeneveld J, Iapichino G, Leverve X, Nitenberg G, Singer P, Wernerman J, Joannidis M, Stecher A, Chioléro R (2009) A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med 35(10):1738–1748
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R (2013) Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 41(2):580–637
Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T, German Interdisciplinary Association for Intensive and Emergency Care Medicine, German Sepsis Society (2010) Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI). Anaesthesist 59(4):347–370
Finfer S, Wernerman J, Preiser JC, Cass T, Desaive T, Hovorka R, Joseph JI, Kosiborod M, Krinsley J, Mackenzie I, Mesotten D, Schultz MJ, Scott MG, Slingerland R, Van den Berghe G, Van Herpe T (2013) Clinical review: consensus recommendations on measurement of blood glucose and reporting glycemic control in critically ill adults. Crit Care 17(3):229–214
Kanji S, Buffie J, Hutton B et al (2005) Reliability of point-of-care testing for glucose measurement in critically ill adults. Crit Care Med 33(12):2778–278512
Pidcoke HF, Wade CE, Mann EA et al (2010) Anemia causes hypoglycemia in intensive care unit patients due to error in singlechannelglucometers: methods of reducing patient risk. Crit Care Med 38:471–476
Mesotten D (2013) Continuous glucose sensors for glycaemic control in the ICU: have we arrived? Crit Care 17(5):1004
Klemperer JD, Klein I, Gomez M, Helm RE, Ojamaa K, Thomas SJ, Isom OW, Krieger K (1995) Thyroid hormone treatment after coronary-artery bypass surgery. N Engl J Med 333(23):1522–1527
Brent GA, Hershman JM (1986) Thyroxine therapy in patients with severe nonthyroidal illnesses and low serum thyroxine concentration. J Clin Endocrinol Metab 63:1–8
Van den Berghe G, Wouters P, Weekers F et al (1999) Reactivation of pituitary hormone release and metabolic improvement by infusion of growth hormone-releasing peptide and thyrotropin-releasing hormone in patients with protracted critical illness. J Clin Endocrinol Metab 84:1311–1323
Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troché G, Chaumet-Riffaud P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288(7):862–871
Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J, CORTICUS Study Group (2008) Hydrocortisone therapy for patients with septic shock. N Engl J Med 358(2):111–124
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
K. Pilarczyk, R. Martini, M. von der Brelie und N. Haake geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
Rights and permissions
About this article
Cite this article
Pilarczyk, K., Martini, R., von der Brelie, M. et al. Störungen des Endokriniums auf der herzchirurgischen Intensivstation. Z Herz- Thorax- Gefäßchir 29, 321–329 (2015). https://doi.org/10.1007/s00398-015-0027-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00398-015-0027-4