Analysis of the Relation between Mortality and Single Dose and Maintenance Cholecalsiferol Treatment in Patients with Vitamin D Deficiency on Admission to Intensive Care Unit


Thesis Type: Expertise In Medicine

Institution Of The Thesis: Ankara Yildirim Beyazit University, Tıp Fakültesi, Anesteziyoloji Ve Reanimasyon Ana Bilim Dalı, Turkey

Approval Date: 2018

Thesis Language: Turkish

Student: Cemile BALCI ALTIN

Supervisor: SEVAL İZDEŞ

Abstract:

Infection and ensuing sepsis are the most significant factors to increase mortality in critically ill patients in the Intensive Care Unit (ICU). Due to its wide-range pathophysiology and a scarcity in treatment methods, it is a difficult disease to overcome. It is still a hypothesis that supplementing critically ill patients with vitamin D, which has an immunomodulatory effect among many others, will have a recuperatory effect against sepsis. Our purpose in this study was to determine whether enteral cholecalciferol treatment in two different doses is related to the infection factor, sepsis and mortality in critically ill patients with vitamin D deficiency in the ICU. The study included all patients older than 18 years of age not meeting the exclusion criteria, who were admitted to and expected to stay for more than 24 hours at a medical-surgical mixed type ICU of 20 beds throughout 2016 and 2017. Vitamin D levels of all included patients were measured within 24 hours of admission and patients were classified into four distinct groups; patients with normal vitamin D levels, patients with low vitamin D levels that did not recieve treatment, patients with low vitamin D levels that were treated with a single 300.000 IU bolus dose of enteral cholecalciferol, and finally patients with low vitamin D levels that were treated with 300.000 IU bolus dose of enteral cholecalciferol followed by a daily dose of 2000 IU cholecalciferol. Demographic data, clinical prognosis indicators such as Acute Physiology and Chronic Health Evaluation (APACHE-II), Sequential Organ Failure Assessment (SOFA), Glasgow Coma Scale (GCS) scores, sepsis, septic shock and Multiple Organ Dysfunction Syndrome (MODS) diagnosis were recorded at the time of admittance and during the ICU stay. Also recorded were ICU and hospital stay lengths, clinical outcomes, infection indicators, and renal and liver function test results. These recordings were used for comparison between each group of patients. 210 patients were included in total, 185 of which had low vitamin D levels (61.08% with severe deficiency, 24.32% with deficiency, and 14.59 with insufficiency). When compared to the remaining patients, emergence of sepsis in the patients with low vitamin D levels were significantly more frequent (p < 0.05). And frequency of sepsis, septic shock and MODS in patients with severe vitamin D deficiency were found to be significantly higher than patients with normal vitamin D levels (p < 0.05). Patients with higher parathormon (PTH) levels were observed to be older, have higher body mass index (BMI), and a higher frequency of immobility and traditional clothing (p < 0.05). Patients with higher PTH also had significantly longer stay, and significantly higher APACHE-II and SOFA scores compared to patients with normal PTH levels. This group also had significantly higher mortality and higher frequency of sepsis, septic shock, MODS, and Acute Renal Failure (ARF) both at admittance and during ICU stay (p < 0.05). However, no difference between the vitamin D levels of these two groups were detected (p < 0.05). MODS diagnosis frequency at admittance was significantly higher for the group that did not receive vitamin D treatment (p <0.05). In addition to this, mortality and frequency of sepsis, septic shock, MODS, and ARF was higher with the group of patients that did not receive vitamin D treatment (p < 0.05). Although statistically not significant, mortality and frequency of sepsis, septic shock and MODS were observed to be higher for the group that received a single dose of cholecalciferol when compared to the group that received additional maintenance treatment (Table 5.3., Table 5.5.). In conclusion, although some more comprehensive studies need to be done on vitamin D and PTH in critically ill patients, it was determined that patients with vitamin D deficiency or patients with normal vitamin D levels but high PTH levels are more prone to sepsis, septic shock and MODS. It was also observed that high levels of PTH increases mortality by affecting the course of critical illness. Even though patients that received single dose treatment and patients that received additional maintenance treatment demonstrated similar courses of improvement in terms of vitamin D levels, since frequency of sepsis, septic shock and MODS were lower during ICU stay with the group that received follow-up doses, it is concluded that this type of treatment is better compared to a single dose treatment.