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574 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Research vignette, Continued
attenuated when patients received ACEI therapy at admission. therapy including recorded duration of administration (pretreat-
Consequently, effectiveness of ACEI therapy should be validated in ment, duration of treatment and discontinuation) was retrieved
a prospective trial. from a database, along with medication list, 28-day, 180-day,
Critique 365-day mortality and severity of illness score. Heart rate variability
The researchers set the background to the work by drawing atten- was obtained from 24-hour continuous Holter ECG recordings.
tion to two factors associated with MODS: autonomic dysfunction Patient population showed similar age, APACHE II and SOFA scores;
and the immune response that leads to vascular and cellular organ 20 female/68 male patients received ACEI and 38 female/110 male
dysfunction. The authors describe how inflammatory mediators without ACEI.
activate sensory pathways which stimulate a cholinergic antiin- The authors suggest that the mechanisms behind mortality reduc-
flammatory reaction to prevent leakage of proinflammatory medi- tion in the MODS patient receiving ACEI therapy appear multifac-
ators into the circulation. They put forward the concept that this eted. ACEI may affect inflammatory reactions through modulation
antiinflammatory vagal pathway might be suppressed in sepsis of the renin–angiotensin–aldosterone system which has not only
and MODS and strategies to modulate both systems may have vasoconstrictive actions but also pro-inflammatory properties. In a
prognostic implications. MODS patient autonomic function is blunted. Modulation of the
renin–angiotensin–aldosterone system with ACEI therapy increases
Further, the authors reiterate the association between patients autonomic control of heart rate and reduction in adrenergic activ-
receiving statin therapy and reduced inflammation and subse- ity. This means that cardiovascular reflexes are optimised and there
quent rate of severe sepsis, ICU admission and mortality in patients is a decrease in myocardial oxygen demand. MODS patients on
admitted to hospital with acute bacterial infection. This is further ACEI had an improved parasympathetic modulation of heart rate
reported as improved outcome in MODS patients receiving statin compared to those not receiving ACEI.
therapy versus those that did not, attributed to improved endothe-
lial function, reduced inflammation and improved autonomic func- The study results suggested that MODS patients receiving ACEI
tion. Recent work in the area of statin therapy has been reported therapy may have significantly reduced 28-day, 180-day and
demonstrating that chronic statin therapy was associated with 365-day mortality compared to those not receiving ACEIs. There
decreased mortality in postoperative patients who had major did not appear to be a difference in one-year mortality comparing
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adverse outcomes such as MODS. This paper therefore sets the early and later ACEI administration. Patients receiving ACEI treat-
scene to present a strong argument to support the research aims ment had less attenuated HRV, probably by preventing a reduction
of investigating whether ACEI is associated with reduced mortality in vagal tone and therefore modulating the inflammatory response.
in MODS; whether a potential reduction in mortality is seen only The study was well designed, although data were retrospectively
in cardiogenic triggered MODS; and whether the time of ACEI analysed using a small population of MODS patients. Despite this
application has impact on outcome. The hypothesis was that ACEI limitation, it is a significant study in relation to mortality outcomes
therapy could be advantageous for MODS patients despite its for patients with MODS that should encourage future prospective
blood-pressure-lowering features.
trials. Along with earlier work on statin therapy, ACEI treatment
An independent observer conducted a retrospective analysis of strategies may provide additional mortality benefits that translate
mortality for 178 MODS patients with or without ACEI therapy. ACEI into improved health care outcomes for critically ill patients.

Learning activities

1. Review the coagulation cascade and inflammatory and 5. Think of a patient with MODS who you have recently cared for.
immune functions of the body. Reflect on the important elements of your nursing care that
2. Review the role of the adrenal gland and its relationship to allowed you to effectively manage this patient. Consider what
adrenal insufficiency in the patient with MODS. aspects of your care you would like to change when you next
3. Develop a care plan for Mr Wyland (discussed in the case study) care for a complex MODS patient.
for his ICU stay. Ensure that you include routine cares as well 6. Review the pharmacology, therapeutic actions and interac-
as care specifically targeted at organ support. Discuss your tions of statins and ACEI. Using the evidence based literature,
plan with an experienced colleague. consider their application in patients with MODS.
4. List some of the important assessment findings that influenced
the care of Mr Wyland during his stay in ICU, e.g. increasing
bronchospasm, unstable BGLs, quiet bowel sounds.