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Avaliação do selénio, zinco e cobre séricos numa Unidade de Cuidados Intensivos : sua relação com a evolução e o prognóstico dos doentes
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Introdução: O selénio, o zinco e o cobre, são oligoelementos considerados importantes na resposta anti-inflamatória / antioxidante, sendo o objetivo deste trabalho relacionar as suas concentrações séricas com a gravidade, a evolução clínica e o prognóstico.
Material e Métodos: Realizou-se um estudo prospetivo na UCI do Hospital Beatriz Ângelo, durante 4 meses, com 200 doentes, tendo sido realizados doseamentos séricos de selénio, zinco, cobre e marcadores de fase aguda, na admissão e ao terceiro dia de internamento.
Resultados: Na admissão os doentes com duas ou mais falências de órgãos e os doentes com necessidade de suporte aminérgico apresentaram níveis de zinco e selénio significativamente mais baixos (p <0,01); os níveis séricos de zinco também eram significativamente mais baixos nos doentes ventilados (p = 0,05). Tempos mais prolongados de ventilação mecânica estavam associados a valores significativamente mais baixos de zinco e selénio na admissão (p = 0,014 e p = 0,037, respetivamente). Os doentes com falência renal e hematológica apresentaram valores mais baixos de selénio na admissão (p = 0,002 e p = 0,028, respetivamente). Verificou-se uma relação significativa entre os marcadores de fase aguda e os níveis de zinco (p = 0,004) e de selénio (p = 0,005).
Os doentes que desenvolveram complicações infeciosas durante o internamento apresentaram níveis significativamente mais altos de cobre na admissão (p = 0,007). Analisou-se a variação dos níveis dos oligoelementos entre o primeiro e o terceiro dia de internamento, assim como da sua relação com o início precoce da dieta na UCI.
Conclusão: Os doentes mais graves apresentaram níveis séricos de selénio e zinco mais baixos. A concentração sérica de cobre apresentou-se elevada na admissão, em alguns doentes, ao contrário do selénio e do zinco. Considerar que estes níveis alterados têm implicação causal na gravidade da situação clínica, ou são consequência da mesma, ficará em aberto.
Background/ objectives: Selenium, zinc and copper are trace elements and have important antioxidant and anti-inflammatory properties. The main purpose of this study was to evaluate these trace elements plasmatic levels and correlate them with other blood values and with organ failure indicators, with the clinical evolution (ICU length of stay, ventilation period, vasopressor needs, infectious complications and renal function substitution needs). It was also intended to evaluate the relation between trace elements and acute- phase proteins and to establish a connection between trace elements levels and ICU and hospital prognosis. Subjects/ methods: It was a prospective study, with four months duration, and included 200 patients. Patients were enrolled after satisfying the inclusion criteria. The study took place in the Intensive Care Unit of Beatriz Ângelo’s Hospital. Blood samples were taken to obtain the plasma levels of selenium, zinc, copper and other biomarkers at the admission to the ICU and on the third day in ICU. Results: A total of 200 consecutive patients (59% males, 41% females; median age 65,8 years; age range 22 - 90 years) were included. Their median SAPS II and APACHE II scores were 42,96 ± 21,05 and 19,46 ± 10,4, respectively. Regarding the severity of disease, at admission, 69,5% of the patients had two or more organ failures, 19,5% had one organ failure and 11% had no organ failure. Normal trace elements blood values are discussed on ICU patients. On admission low zinc levels were present in almost 74% of our patients, 20% of the patients had low selenium levels and 8% had high copper levels, based on the normal population reference levels. We compared trace element levels from the first to the third day on ICU and there was a significant increase of zinc levels (p = 0,011). Selenium and copper levels were not significantly changed. There was a link between higher copper levels at admission and higher corporal mass index (p = 0,002). There was no relation between trace elements levels and ICU length of stay, ICU mortality or hospital mortality. On admission, patients with multiple organ failure had significant lower zinc (p = 0,004) and selenium (p = 0,005) levels. Patients with respiratory failure or on vasopressors had significant lower zinc levels too (p = 0,05 and p = 0,000, respectively). Selenium plasmatic levels were also lower in patients with haemodynamic (p = 0,002), haematological (p = 0,028) and renal (p = 0,002) failure. Longer periods of ventilation were associated with significant lower zinc and selenium levels (p = 0,014 and p = 0,037, respectively). Copper levels were significantly lower in respiratory failure patients (p = 0,047) and higher in patients with infectious complications (p = 0,007). There was a significant relation between organ failure, and zinc (p = 0,004) and selenium (p = 0,005) levels. There was an important decrease on zinc levels from critical patients with one organ failure to patients with multiple organ failure (p = 0,098). It also occurred with selenium levels, decreasing from none to multiple organ failure (p = 0,067). We analyzed the relation between trace element and acute phase protein levels. Zinc levels were positively related with albumin (r = 0,230; p = 0,001) and negatively related with CRP (r = - 0,251; p < 0,001). Since albumin is a negative acute phase protein marker and CRP a positive marker, this kind of variation with zinc levels was expected. Selenium levels were positively related with albumin (r = 0,454; p < 0,001), prealbumin (r = 0,432; p <0,001) and transferrin (r = 0,357; p < 0,001), and negatively related with ferritin (r = - 0,183; p = 0,011) and CRP (r = - 0,473; p < 0,001). This kind of variation with selenium levels was expected for these acute proteins, except for transferrin. Since transferrin is a positive acute phase protein, it would be expected its levels to rise with inflammation, as selenium levels decreased. Copper levels were positively related with transferrin (r = 0,186; p = 0,011) and albumin (r = 0,171; p = 0,019). Copper levels are high on the beginning of the inflammatory process, so the positive relation with transferrin was expected. We also analyzed the differences between these trace elements from the first to the third day, and compared it with the clinical evolution, with early nutritional support and with ICU and hospital prognosis. In our study, zinc levels increased from the first to the third day in ICU, in a significant way, concerning patients who started to eat during the first 48 hours (p < 0,001). There was no relation between changes in the trace elements levels from the first to the third day on ICU and the severity markers (SAPS II, APACHE II), nor with ICU or hospital mortality. There was also no relation between the change in the trace elements levels from the first to the third day on ICU and the presence of an organ failure or the number of organ failures. Conclusion: Patients with worst situations had generally lower selenium and zinc levels. Copper levels are described as initially increased in major inflammatory processes. In our study, some patients had high copper levels at admission, opposite to zinc and selenium. It is possible that the zinc levels increase from the first to the third day is influenced by nutritional support. We still don´t know if these changed trace elements levels were a consequence of critical illness, caused by inflammation, with redistribution in body and increased losses, or if lower blood trace elements levels had causal clinical implications on severity and evolution.
Background/ objectives: Selenium, zinc and copper are trace elements and have important antioxidant and anti-inflammatory properties. The main purpose of this study was to evaluate these trace elements plasmatic levels and correlate them with other blood values and with organ failure indicators, with the clinical evolution (ICU length of stay, ventilation period, vasopressor needs, infectious complications and renal function substitution needs). It was also intended to evaluate the relation between trace elements and acute- phase proteins and to establish a connection between trace elements levels and ICU and hospital prognosis. Subjects/ methods: It was a prospective study, with four months duration, and included 200 patients. Patients were enrolled after satisfying the inclusion criteria. The study took place in the Intensive Care Unit of Beatriz Ângelo’s Hospital. Blood samples were taken to obtain the plasma levels of selenium, zinc, copper and other biomarkers at the admission to the ICU and on the third day in ICU. Results: A total of 200 consecutive patients (59% males, 41% females; median age 65,8 years; age range 22 - 90 years) were included. Their median SAPS II and APACHE II scores were 42,96 ± 21,05 and 19,46 ± 10,4, respectively. Regarding the severity of disease, at admission, 69,5% of the patients had two or more organ failures, 19,5% had one organ failure and 11% had no organ failure. Normal trace elements blood values are discussed on ICU patients. On admission low zinc levels were present in almost 74% of our patients, 20% of the patients had low selenium levels and 8% had high copper levels, based on the normal population reference levels. We compared trace element levels from the first to the third day on ICU and there was a significant increase of zinc levels (p = 0,011). Selenium and copper levels were not significantly changed. There was a link between higher copper levels at admission and higher corporal mass index (p = 0,002). There was no relation between trace elements levels and ICU length of stay, ICU mortality or hospital mortality. On admission, patients with multiple organ failure had significant lower zinc (p = 0,004) and selenium (p = 0,005) levels. Patients with respiratory failure or on vasopressors had significant lower zinc levels too (p = 0,05 and p = 0,000, respectively). Selenium plasmatic levels were also lower in patients with haemodynamic (p = 0,002), haematological (p = 0,028) and renal (p = 0,002) failure. Longer periods of ventilation were associated with significant lower zinc and selenium levels (p = 0,014 and p = 0,037, respectively). Copper levels were significantly lower in respiratory failure patients (p = 0,047) and higher in patients with infectious complications (p = 0,007). There was a significant relation between organ failure, and zinc (p = 0,004) and selenium (p = 0,005) levels. There was an important decrease on zinc levels from critical patients with one organ failure to patients with multiple organ failure (p = 0,098). It also occurred with selenium levels, decreasing from none to multiple organ failure (p = 0,067). We analyzed the relation between trace element and acute phase protein levels. Zinc levels were positively related with albumin (r = 0,230; p = 0,001) and negatively related with CRP (r = - 0,251; p < 0,001). Since albumin is a negative acute phase protein marker and CRP a positive marker, this kind of variation with zinc levels was expected. Selenium levels were positively related with albumin (r = 0,454; p < 0,001), prealbumin (r = 0,432; p <0,001) and transferrin (r = 0,357; p < 0,001), and negatively related with ferritin (r = - 0,183; p = 0,011) and CRP (r = - 0,473; p < 0,001). This kind of variation with selenium levels was expected for these acute proteins, except for transferrin. Since transferrin is a positive acute phase protein, it would be expected its levels to rise with inflammation, as selenium levels decreased. Copper levels were positively related with transferrin (r = 0,186; p = 0,011) and albumin (r = 0,171; p = 0,019). Copper levels are high on the beginning of the inflammatory process, so the positive relation with transferrin was expected. We also analyzed the differences between these trace elements from the first to the third day, and compared it with the clinical evolution, with early nutritional support and with ICU and hospital prognosis. In our study, zinc levels increased from the first to the third day in ICU, in a significant way, concerning patients who started to eat during the first 48 hours (p < 0,001). There was no relation between changes in the trace elements levels from the first to the third day on ICU and the severity markers (SAPS II, APACHE II), nor with ICU or hospital mortality. There was also no relation between the change in the trace elements levels from the first to the third day on ICU and the presence of an organ failure or the number of organ failures. Conclusion: Patients with worst situations had generally lower selenium and zinc levels. Copper levels are described as initially increased in major inflammatory processes. In our study, some patients had high copper levels at admission, opposite to zinc and selenium. It is possible that the zinc levels increase from the first to the third day is influenced by nutritional support. We still don´t know if these changed trace elements levels were a consequence of critical illness, caused by inflammation, with redistribution in body and increased losses, or if lower blood trace elements levels had causal clinical implications on severity and evolution.
Descrição
Tese de mestrado, Nutrição Clínica, Universidade de Lisboa, Faculdade de Medicina, 2019
Palavras-chave
Oligoelementos Selénio Zinco Cobre Doentes criticos Teses de mestrado - 2019