Critical illness trauma and surgery

Critical illness, trauma, burns, surgery and malnutrition all result in a catabolic state characterised by acute muscle breakdown which is reversed during recovery. These catabolic states are characteristically accompanied by functional hypogo-nadotrophic, androgen deficiency. This is due to functional partial GnRH deficiency as pulsatile GnRH administration can rescue LH pulsatility and hypoandrogenemia (Aloi et al. 1997; van den Berghe et al. 2001). This has long led to the hypothesis that androgen therapy might improve mortality or morbidity by pharmacologically enhancing nutritional supplementation and muscle, bone and skin recovery. However, the endocrine response to catabolic states such as critical illness are highly complex involving widespread dysregulation of all pituitary hormonal axes (Van den Berghe 2003) so that restoration of individual anabolic hormones may be inadequate. Nevertheless the success of intensive insulin therapy to regulate hyperglycemia (van den Berghe et al. 2001) and the promise of combination pituitary hormonal approaches (Van den Berghe et al. 2002) indicates that hormonal regimens are promising. Key outcome variables for evaluating the efficacy of androgen therapy in such catabolic states include (a) muscle mass and strength, (b) bone turnover and wound healing (particularly after burns) as well as (c) health service utilization variable such as duration of in-hospital stay and rate and extent of rehabilitation.

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