Elevated amylase and lipase levels in the neurosurgery intensive care unit

Skeletal Muscle Myokine Expression in Critical Illness, Association With Outcome and Impact of Therapeutic Interventions

Context

Muscle expresses and secretes several myokines that bring about benefits in distant organs.

Objective

We investigated the impact of critical illness on muscular expression of irisin, kynurenine aminotransferases, and amylase; association with clinical outcome; and impact of interventions that attenuate muscle wasting/weakness.

Methods

We studied critically ill patients who participated in 2 randomized controlled trials (EPaNIC/NESCI) and documented time profiles in critically ill mice. Included in the study were 174 intensive care unit (ICU) patients (day 8 ± 1) vs 19 matched controls, and 60 mice subjected to surgery/sepsis vs 60 pair-fed healthy mice. Interventions studied included 7-day neuromuscular electrical stimulation (NMES), and withholding parenteral nutrition (PN) in the first ICU week (late PN) vs early PN. The main outcome measures were FNDC5 (irisin- precursor), KYAT1, KYAT3, and amylase mRNA expression in skeletal muscle.

Results

Critically ill patients showed 34% to 80% lower mRNA expression of FNDC5, KYAT1, and amylases than controls (P < .0001). Critically ill mice showed time-dependent reductions in all mRNAs compared with healthy mice (P ≤ .04). The lower FNDC5 expression in patients was independently associated with a higher ICU mortality (P = .015) and ICU-acquired weakness (P = .012), whereas the lower amylase expression in ICU survivors was independently associated with a longer ICU stay (P = .0060). Lower amylase expression was independently associated with a lower risk of death (P = .048), and lower KYAT1 expression with a lower risk of weakness (P = .022). NMES increased FNDC5 expression compared with unstimulated muscle (P = .016), and late PN patients had a higher KYAT1 expression than early PN patients (P = .022).

Conclusion

Expression of the studied myokines was affected by critical illness and associated with clinical outcomes, with limited effects of interventions that attenuate muscle wasting or weakness.

Evidence showing lipotoxicity worsens outcomes in covid-19 patients and insights about the underlying mechanisms

We compared three hospitalized patient cohorts and conducted mechanistic studies to determine if lipotoxicity worsens COVID-19. Cohort-1 (n = 30) compared COVID-19 patients dismissed home to those requiring intensive-care unit (ICU) transfer. Cohort-2 (n = 116) compared critically ill ICU patients with and without COVID-19. Cohort-3 (n = 3969) studied hypoalbuminemia and hypocalcemia’s impact on COVID-19 mortality. Patients requiring ICU transfer had higher serum albumin unbound linoleic acid (LA). Unbound fatty acids and LA were elevated in ICU transfers, COVID-19 ICU patients and ICU non-survivors. COVID-19 ICU patients (cohort-2) had greater serum lipase, damage-associated molecular patterns (DAMPs), cytokines, hypocalcemia, hypoalbuminemia, organ failure and thrombotic events. Hypocalcemia and hypoalbuminemia independently associated with COVID-19 mortality in cohort-3. Experimentally, LA reacted with albumin, calcium and induced hypocalcemia, hypoalbuminemia in mice. Endothelial cells took up unbound LA, which depolarized their mitochondria. In mice, unbound LA increased DAMPs, cytokines, causing endothelial injury, organ failure and thrombosis. Therefore, excessive unbound LA in the circulation may worsen COVID-19 outcomes.

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Three cohorts of hospitalized COVID-19 patients with different severities were studied

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Severe COVID-19 increased serum linoleic acid (LA) and unbound fatty acid levels

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Endothelial cell uptake of unbound LA dose-dependently depolarized mitochondria

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Unbound LA increased cytokines, endothelial injury, organ failure and thrombosis

Predisposing Factors and Neurologic Outcomes of Patients with Elevated Serum Amylase and/or Lipase after Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study

This study investigated the patient outcomes, incidence, and predisposing factors of elevated pancreatic enzyme levels after OHCA. We conducted a retrospective cohort study of patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). Elevation of pancreatic enzyme levels was defined as serum amylase or lipase levels that were at least three times the upper limit of normal. The factors associated with elevated pancreatic enzyme levels and their association with neurologic outcomes and mortality 28 days after OHCA were analyzed. Among the 355 patients, 166 (46.8%) patients developed elevated pancreatic enzyme levels. In the multivariable analysis (odds ratio, 95% confidence interval), initial shockable rhythm (0.62, 0.39−0.98, p = 0.04), time from collapse to return of spontaneous circulation (1.02, 1.01−1.04, p < 0.001), and history of coronary artery disease (1.7, 1.01−2.87, p = 0.046) were associated with elevated pancreatic enzyme levels. After adjusting for confounding factors, elevated pancreatic enzyme levels were associated with neurologic outcomes (5.44, 3.35−8.83, p < 0.001) and mortality (3.74, 2.39−5.86, p < 0.001). Increased pancreatic enzyme levels are common in patients treated with TTM after OHCA and are associated with unfavorable neurologic outcomes and mortality at 28 days after OHCA.

Hyperlipasemia in critically ill dogs with and without acute pancreatitis: Prevalence, underlying diseases, predictors, and outcome

Background

Hyperlipasemia is frequent in critically ill people without evidence of acute pancreatitis (AP), and has been associated with increased morbidity and mortality.

Objective

To evaluate the prevalence of hyperlipasemia at admission and development of hyperlipasemia during hospitalization in critically ill dogs, explore factors associated with hyperlipasemia, and evaluate association with outcome.

Animals

Critically ill, client owned dogs (n = 1360), presented on emergency and admitted to the intensive care unit, that had 1,2‐o‐dilauryl‐rac‐glycero‐3‐glutaric acid‐(6′‐methylresorufin) ester (DGGR) lipase activity measured within 24 hours of admission.

Methods

Retrospective cross‐sectional study of clinical and laboratory records.

Results

The DGGR lipase activity was increased >3× the upper reference limit at admission in 216/1360 (16%) dogs, of which 70/216 (32%) had a clinical diagnosis of AP. Other primary conditions associated with hyperlipasemia were renal, endocrine, and immune‐mediated diseases, and upper airway obstruction. Predictors of hyperlipasemia at admission were prior glucocorticoid administration, vomiting and abdominal pain, increased age, plasma bilirubin and creatinine concentrations, and decreased hematocrit. Of dogs with repeat measurements, 78/345 (23%) had significantly increased lipase during hospitalization, of which 13/78 (17%) had a clinical diagnosis of AP. Other primary conditions associated with in‐hospital hyperlipasemia were renal and immune‐mediated disorders. Predictors of developing hyperlipasemia during hospitalization were hemodialysis events, increased plasma bilirubin and creatinine concentrations, and decreased hematocrit. Hyperlipasemia both at admission and during hospitalization was associated with longer hospitalization and higher mortality.

Conclusions and Clinical Importance

Significant DGGR‐hyperlipasemia is frequent in critically ill dogs and associated with a variety of nonpancreatic conditions and negative outcome.

The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma

Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.

Identification of Pancreatic Injury in Patients with Elevated Amylase or Lipase Level Using a Decision Tree Classifier: A Cross-Sectional Retrospective Analysis in a Level I Trauma Center

Background: In trauma patients, pancreatic injury is rare; however, if undiagnosed, it is associated with high morbidity and mortality rates. Few predictive models are available for the identification of pancreatic injury in trauma patients with elevated serum pancreatic enzymes. In this study, we aimed to construct a model for predicting pancreatic injury using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry in a Level I trauma center. Methods: A total of 991 patients with elevated serum levels of amylase (>137 U/L) or lipase (>51 U/L), including 46 patients with pancreatic injury and 865 without pancreatic injury between January 2009 and December 2016, were allocated in a ratio of 7:3 to training (n = 642) or test (n = 269) sets. Using the data on patient and injury characteristics as well as laboratory data, the DT algorithm with Classification and Regression Tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: Among the trauma patients with elevated amylase or lipase levels, three groups of patients were identified as having a high risk of pancreatic injury, using the DT model. These included (1) 69% of the patients with lipase level ≥306 U/L; (2) 79% of the patients with lipase level between 154 U/L and 305 U/L and shock index (SI) ≥ 0.72; and (3) 80% of the patients with lipase level <154 U/L with abdomen injury, glucose level <158 mg/dL, amylase level <90 U/L, and neutrophil percentage ≥76%; they had all sustained pancreatic injury. With all variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 91.4% and specificity of 98.3%) for the training set. In the test set, the DT achieved an accuracy of 93.3%, sensitivity of 72.7%, and specificity of 94.2%. Conclusions: We established a DT model using lipase, SI, and additional conditions (injury to the abdomen, glucose level <158 mg/dL, amylase level <90 U/L, and neutrophils ≥76%) as important nodes to predict three groups of patients with a high risk of pancreatic injury. The proposed decision-making algorithm may help in identifying pancreatic injury among trauma patients with elevated serum amylase or lipase levels.

Forensic and clinical significance of serum amylase, lipase and gamma glutamyl transferase as predictors of outcome in head injured patients

Head trauma is one of the leading causes of death and disability worldwide. Combined head lesions consist of more than one form of lesions. Biochemical markers of brain injury are used in determining the extent of brain injury and predicting its outcomes. The aim of this study was to investigate the forensic and clinical significance of serum amylase, lipase and gamma glutamyl transferase (GGT) as predictors of the outcome in head injured patients.

PATIENTS AND METHODS

Sixty head injured patients were enrolled and subjected to personal history taking, general and local physical examination. Glasgow coma scale (GCS), head computed tomography scan and pelvi-abdominal ultrasound were performed. Two blood samples (each 3 mL) were drawn at the time of admission and after 24 h for measuring serum amylase, lipase and GGT levels using special kits.

RESULTS

Most cases of head trauma occurred accidentally during daytime, in the street as a result of falls and road traffic accidents (RTA). Significant increase of serum amylase, lipase and GGT levels on re-evaluation after 24 h from admission were demonstrated in combined head lesions. There was a high significant negative correlation between GCS and these enzymes both on admission and 24 h after admission. Serum levels of measured enzymes were significantly higher in non-survivors as compared to survivors.

CONCLUSION

Serum amylase, lipase and GGT are good predictors of the outcome in head injured patients. This could be useful for forensic experts to deduce that the poor outcome of the victims was primarily related to the effects of head trauma and its sequences.

Defining the diagnostic value of hyperlipasemia for acute pancreatitis in the critically ill

BACKGROUND/OBJECTIVES

Hyperlipasemia is frequently encountered in patients in the intensive care unit (ICU). The degree to which it should be valued in making the diagnosis of acute pancreatitis (AP) in critically ill patients remains uncertain. We sought to determine the diagnostic accuracy of hyperlipasemia and the optimal lipase cutoff for diagnosing AP in critically ill patients.

METHODS

Four hundred and seventeen ICU patients with hyperlipasemia, defined as lipase greater than three times the upper limit of normal from 2009 to 2012 were retrospectively identified. A diagnosis of AP was confirmed by the additional presence of either characteristic abdominal pain or cross-sectional imaging.

RESULTS

The overall positive predictive value (PPV) of hyperlipasemia was 38.1%. Median initial lipase levels were 1164 IU/L in patients with AP and 284.5 IU/L in patients without AP (p < 0.001). The optimal diagnostic lipase cutoff of 532 IU/L correlated with a sensitivity, specificity, negative predictive value and PPV of 77.4%, 78.0%, 84.9%, and 67.0% respectively. The most common primary diagnoses in non-AP patients with elevated lipase included shock, cardiac arrest and malignancy.

CONCLUSIONS

Physicians should maintain caution when interpreting hyperlipasemia in the critically ill due its relatively low PPV. However, a greater lipase cutoff improves its diagnostic value in AP and helps to reduce unnecessary imaging in these patients.

Association Between the Pancreatic Enzyme Level and Organ Failure in Trauma Patients

BACKGROUND

The literature suggests an association of pancreatic enzymes with systemic inflammation resulting in secondary organ injury and dysfunction following trauma. Elevation in serum enzymes may not always be predictive of pancreatic disease, and can reflect extra pancreatic production.

OBJECTIVES

This study was conducted to evaluate the rise in serum pancreatic enzyme levels with the incidence of organ failure following trauma.

PATIENTS AND METHODS

A retrospective review was performed on critically injured patients from December 2009 to March 2010. Patient's clinical demographics, routine laboratory investigations along with amylase and lipase levels were also extracted from the patients' records. Patients with pancreatic or duodenal injuries were excluded from the study.

RESULTS

From a total of 296 patients (mean age, 31 years), 85% were males. Blunt injury was seen in 91.6% of the cases and 8.4% had penetrating injury. One hundred and fifty-three patients had single organ failure, 96 had multiple organ failure and 47 had no organ failure. There was a significant difference in lipase levels (P = 0.04), potassium levels (P = 0.05) and hemoglobin levels (P = -0.004), among the three patient groups. There was no significant difference in amylase levels among the three patient groups. The observed independent predictors of mortality included coagulopathy (OR = 1.7), Glasgow coma scale (OR = 1.1, 4.7), pulmonary failure (OR = 0.0004), hepatic failure (OR = 0.048), renal failure (OR = 5.5), organ failure (OR =149.8), lipase levels (OR = 1.3), and infection (OR = 3.0).

CONCLUSIONS

There was a significant correlation between elevated lipase levels and the incidence of multiple organ failure. Moreover, No significant association was found between the elevated amylase levels and organ failure. However, on admission, measurement of these enzymes coupled with routine laboratory investigations can be a powerful tool in the early detection of patients progressing towards organ failure.

Significant elevations of serum lipase not caused by pancreatitis: a systematic review

BACKGROUND

Many authors advocate lipase as the preferred serological test for the diagnosis of pancreatitis and a cut-off level of three or more times the upper limit of normal (ULN) is often quoted. The literature contains no systematic review that explores alternative causes of a lipase level over three times as high as the ULN. Such a review was therefore the objective of this study.

METHODS

The EMBASE and MEDLINE databases (1985 to August 2013) were searched for all eligible articles. Predetermined data were extracted and independently analysed by two reviewers.

RESULTS

In total, data from 58 studies were included in the final analysis. The following causes other than pancreatitis of lipase levels exceeding three times the ULN were found: reduced clearance of lipase caused by renal impairment or macrolipase formation; other hepatobiliary, gastroduodenal, intestinal and neoplastic causes; critical illness, including neurosurgical pathology; alternative pancreatic diagnoses, such as non-pathological pancreatic hyperenzymaemia, and miscellaneous causes such as diabetes, drugs and infections.

CONCLUSIONS

A series of differential diagnoses for significant serum lipase elevations (i.e. exceeding three times the ULN) has been provided by this study. Clinicians should utilize this knowledge in the interpretation and management of patients who have lipase levels over three times as high as the ULN, remaining vigilant for an alternative diagnosis to pancreatitis. The medical officer should be aware of the possibility of incorrect diagnosis in the asymptomatic patient.

Clinical and pathologic characteristics of pancreatic necrosis in critically ill children

BACKGROUND

Pancreatic damage in critically ill patients is associated with the progressive failure of multiple organs, but little is known about its clinical characteristics. At present, no guidelines are available for the diagnosis and management of pancreatic damage. This study was undertaken to analyze the clinical and pathologic characteristics of pancreatic necrosis in critically ill children, and to find some biological markers of pancreatic damage or pancreatic necrosis.

METHODS

We retrospectively reviewed the clinical data, laboratory results, and autopsy findings of 25 children, who were admitted to Hunan Children's Hospital, China from 2003 to 2009, and died of multiple organ failure. The autopsy revealed pancreatic necrosis in 5 children, in whom sectional or gross autopsy was performed.

RESULTS

The 5 children had acute onset and a fever. Two children had abdominal pain and 2 had abdominal bulging, flatulence and gastrointestinal bleeding. Four children had abnormal liver function, characterized by decreased albumin and 3 children had elevated level of C-reactive protein (CRP). B-ultrasonography revealed abnormal acoustic image of the pancreas in all children, and autopsy confirmed pancreatic necrosis, which may be associated with the damage of the adrenal gland, liver, lung, heart, spleen, kidney, intestine, thymus, mediastinal and mesenteric lymph nodes and other organs. Children 1 and 2 died of acute hemorrhagic necrotizing pancreatitis (AHNP); children 3-5 died of multiple organ dysfunction syndrome (MODS) due to pancreatic necrosis.

CONCLUSION

Pancreatic damage or pancreatic necrosis in critically ill children is characterized by acute onset, severity, short course, multiple organ damage or failure. It may be asymptomatic in early stage, and easy to be ignored.