Endocrine dysfunction ICU management
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Transcript Endocrine dysfunction ICU management
SURGICAL
CONDITIONS
THYROIDECTOMY
ENDOCRINE DYSFUNCTION - MANAGEMENT
THYROIDECTOMY
TOTAL THYROIDECTOMY – THYROID
REPLACEMENT IS REQUIRED
SUBTOTAL THYROIDECTOMY – USE
SERUM THYROID LEVEL AS AN
INDICATOR
THYROIDECTOMY - MEDICATION
THYROXINE REPLACEMENT
HALF LIFE OF THYROXINE IS FEW DAYS,
THEREFORE CAN WAIT TILL STARTING
RX.
DOSE (L-THYROXINE) : 0.15 – 0.2mg dly
THYROIDECTOMY - MEDICATION
TSH
USED AS SUPPRESSION FOR…
1)NON-TOXIC GOITER
2)OR IF SUBTOTAL THYROIDECTOMY
3)FOR TOTAL THYROIDECTOMY FOR
THYROID CA (SELECTED CASES)
DOSE : 0.2 – 0.4mg dly
THYROIDECTOMY - MEDICATION
PROPANOLOL
IF PT WAS GIVEN PRE-OP
PROPANOLOL, ADVISABLE TO CONTINUE
2 -3 DAYS POST OP.
THYROIDECTOMY - MEDICATION
HYPOPARATHYROIDISM
Hypoparathyroidism can occur post
surgery.
More likely in extensive dissection for
diffuse nature or malignancy (esp. radical
neck dissection)
THYROIDECTOMY - MEDICATION
THYROID STORM
MX OVERVIEW
Can occur as a complication post
surgery.
Manage precipitating factors
Reduce synthesis and release of thryoid
hormones.
Reduce peripheral conversion of T4 to
T3.
THYROIDECTOMY – THYROID STORM
SUPPORTIVE MEASURES
These pts are hypermetabolic and need
more fluids electrolytes and glucose.
Bring down fever (but don’t use
salicylates – they diplace thyroid
hormones from their binding prots.)
Plasma exchange as last resort – not
proven to work
THYROIDECTOMY – THYROID STORM
B-ADRENERGIC BLOCKERS
FUNCTIONS
Antagonises the effect of thyroid
hormones.
Decreases the
hypersensitivity to
cathecholamines.
THYROIDECTOMY – THYROID STORM
B-ADRENERGIC BLOCKERS
PROPANOLOL
Drug of choice as it also inhibits
peripheral conversion of t4 to t3
It promptly treats the tachycardia, fever,
hyperkinesis & tremor
IV doses of 0.5mg with cardiac
monitoring up to 10mg
Give more 4-6 hrly
THYROIDECTOMY - THYROID STORM
B-ADRENERGIC BLOCKERS
OTHER AGENTS
B1 selective agents not as good – do not
inhibit T4 to T3
Use when Propanolol contra-indicated.
Esmolol 250-500micg/kg bolus followed
by 50-100mcg/kg/min.
(Diltiazam also good in reducing pulse
rate.)
THYROIDECTOMY - THYROID STORM
CORTICOSTEROIDS
Given because of the relative
deficiency.
Also used beacue they inhibit periph.
conversion T4 to T3.
Hydrocortisone 100mg ivi 6hrly or
Dexamethasone 5mg ivi 12 hrly
THYROIDECTOMY - THYROID STORM
THIONAMIDES
Propylthiouracil
No parental form avail. – and in thyrotox, GI absorp is down
Rapid onset
Function – blocks iodination of Tyrosine and inhib of periph.
Conversion (T4 – T3)
Dose: 100mg loading then 100mg 2 hrly
Methimazole
Slower onset, but longer action.
Does not inhibit periph. Conversion (T4-T3)
Dose: 100mg bolus then 20mg 8hrly
Carbimazole
It is metabolised to methimazole
For all…..
Transient leukopaenia
(20%). Agranulocytosis
is rare
THYROIDECTOMY - THYROID STORM
IODINE
In large doses, it inhibits synthesis and
release of thyroid hormones
Give 1 hr after thioamides
Preps are Lugol’s iodine(oral),
potassium iodide, sodium iodide
Dose: Sodium iodide 1g ivi 12hrly or
equiv oral doses
Iodine containing contrast media are
very good as they are more potent
inhibiters of periph conversion.
THYROIDECTOMY - THYROID STORM
LITHIUM CARBONATE
Used for patients allergic to iodine.
Similar action
Dose: 500-1500mg dly.
Drug monitoring of Lithium.
THYROIDECTOMY - THYROID STORM
DIGOXIN
Use if AF or heart failure present.
Larger than normal doses because of
the high BMR
THYROIDECTOMY - THYROID STORM
AMIODARONE
Controls Arrythmias
Inhibits peripheral conversion of T4 to
T3.
THYROIDECTOMY - THYROID STORM
THYROIDECTOMY – MORE COMPLICATIONS
MYXOEDEMA COMA
Thyroid hormones
T3 best idea.
Dose: 20mcg/d.
T4 not good because periph. conversion is decreased.
Steroids
Given because these pts have impaired glucocorticoid
response to stress., or co-existant adrenal insuff. (Schmidt’s
syndrome)
Dose: Hydrocortisone 200-300mg/d
Supportive
These pts have reduced response to hypoxia and hypercarbia, and
decreased GCS, so ventilation often required.
Warm to treat hypothermia
Rx hyponatraemia, hypoglycaemia
PARATHYROIDECTOMY
PARATHYROIDECTOMY
INTRO
Adenoma and hyperplasia. Removal of
multiple glands usually with hyperplasia.
Transient hypopara. after gland
removal.
Suppression of normal glands
If hypocalcaemia occurs within the first
12-18 hrs, then it is likely to be severe.
PARATHYROIDECTOMY
CALCIUM REPLACEMENT
Mild hypocalcaemia – just watch
Mild hypocal with tingling of lips,
fingers, toes – oral therapy.
Tetany – IVI Calcium
NB – pts on digitalis are more
susceptible to arrthmias
Vit D is usually withheld for 4 – 6 weeks,
unless it is difficult to maintain the Ca.
Parathyroids usually recover within this
period.
PARATHYROIDECTOMY
HYPOCALCAEMIA – GENERAL ASPECTS
Generally a problem in 70-90% of ICU
patients.
IVI calcium…
Two forms. Chloride and gluconate.
Diff. btw 2 is the amount of elemental ca
avail at equiv volumes
Avoid rapid admin – causes nausea, flushing, headache
arrythmias.
Dose – 100mg bolus, then 1-2mg/kg
If not coming up with IVI replacement – consider Mg
deficiency
Calcitrol is usually used for the more chronic conditions.
ADRENALECTOMY
ADRENALECTOMY
ADRENALECTOMY – INDICS.
Bilateral adrenalectomy most often
done for disseminated breast CA.
Old days, done for HPT. Now medical
mx is good enough
Hyperplastic states from pituitary
tumours
Neoplasms
ADRENALECTOMY
MANAGEMENT
Treat complications - bleeding,
pneumothorax, esp if 12th rib is resected.
Ileus following retroperitoneal
dissection.
Treat Adrenocortical Insufficiency…
ADRENALECTOMY
ADRENOCORTICAL INSUFFICIENCY
Be aggressive. Start even before blood
levels available.
Anticipate who will need –
Adrenalectomy, pt’s who are supressed
from steroid therapy, pt’s with adrenal or
pituatary disease.
Do not replace as a ‘standard’.
ADRENALECTOMY
ADRENOCORTICAL INSUFFICIENCY
Start replacement with induction of
anaesthesia.
Start with Dexamthasone 10mg IVI,
together with ACTH 0.25 ivi (synacthen)
Continue steroid replacement with
Hydrocortisone 100mgiv 6-8hrly. Taper.
Taper then to oral.
Hydrocortisone has sufficient
mineralocrticoid component.
ADRENALECTOMY
GENERAL MEASURES
Avoid opiates and sedatives
Correct electrolyte and glucose
Fluid balance
Ecg monitoring
Treat shock
Fluids need to be aggressive initially
PHAEOCHROMOCYTOMA
PHAEOCHROMOCYTOMA
GENERAL
Tumour of the Adrenal Medulla
No other surgical problems for
consideration in the adrenal medulla
PHAEOCHROMOCYTOMA
PROCEDURES DURING SURGERY
Prep for surgery: alpha-adrenergic
blocker as soon as dx made
Phenoxybenzamine 10-100mg b.d. for at
least 3 d before Sx.
Phentolamine (1-5mg) can be used for
immed effect if the BP rises during sx
Approp. inotropes and volume
expanders to be used if BP drops after
removal.
Propanolol can be used pre, intra, and
post op to prevent and Rx cardiac
arrythmias. Oral or IVI (10th the oral
dose).
PHAEOCHROMOCYTOMA
POST SURGERY
Few days post Sx: urinary
Vanillymandelic Acid and
Cathecholamines to verify proper
removal of tumour.
If bilateral adrenalectomy was done –
consider corticosteroid replacement.
PITUITARY
SURGERY
PITUATARY SURGERY
INTRO
ACTH replacement must be given as
described
Remember, with pharmacologic doses
of steroids, underlying diabetes may be
unmasked, and DKA etc must be
managed.
PITUATARY SURGERY
ADH DEFICIENCY
This occurs unless the stalk is left
intact, there may be no deficiency.
Triphasic response to sx….
1)Immed post sx – polyuria and polydipsia
– 4 to 5 days
2)Intense anti-diuresis for 6 days
3)Permanent poyuria and polydipsia (DI)
Phase one is due to damage to hypothalamus tissue and
hormone not released.
Phase 2 is due to degeneration of hormone laden stores.
Fluid admin during this phase will not induce the usual
diuretic response.
PITUATARY SURGERY
ADH DEFICIENCY
MANAGEMENT
During polyuric phase – watch fluid
balance and electrolytes carefully.
Rx with ADH to decrease urine to
normal values, withan increasein
specific gravity.
DDAVP is treatmentrx of choice.
NON-SURGICAL
ISSUES
NON-SURGICAL ISSUES
HYPERGLYCAEMIA
INTRO
Hyperglycemia is a common metabolic
feature of severe stress and is becoming
recognized as a harbinger of the severity
and outcome of illness.
The effects of counterregulatory
hormones and pro-inflammatory
cytokines predominate as a cause
Reversing hyperglycemia and insulin
resistance reduces mortality
NON-SURGICAL ISSUES
HYPERGLYCAEMIA
INTRO - CONTINUED
Trials have shown that aggressive
treatment of hyperglycemia has a positive
impact on immune recovery and the recovery
from an MI
One study: Mortality was decreased by 34%
in a surgical ICU by “clamping” the glucose
level between 4.4 and 6.1 mmol/L
Insulin may have anti-inflammatory
properties – but achieving normoglycaemia
more important than insulin dose.
NON-SURGICAL ISSUES
HYPERGLYCAEMIA
INTRO - CONTINUED
BBA’s relieve Stress Hyperglycaemia, thus
implicating cathecholamines to the disorder.
Metformin particularly useful in SH. It
has antihyperglycemic effects via
suppression of glucose production of the
liver as well as having antioxidant
properties – but beware lactic acidosis
GROWTH
HORMONE
NON-SURGICAL ISSUES
GROWTH HORMONE
INTRO
Despite aggressive nutritional support,
critically ill patients remain catabolic
with continued nitrogen loss.
GH supplementation has salutary
anabolic effects in stressful conditions,
but is poven to increase risk of mortality
GH replacement: If GH low, can be
replaced with recombinant GH- appears
safe
NON-SURGICAL ISSUES
GROWTH HORMONE
DELITARIOUS EFFECTS
Oedema
Insulin resistance
Exacerbated microvascular injury in the
face of sepsis
Hyperglycaemia
Induces hepatic enzymes
HPA
INSUFFICIENCY
HPA INSUFFICIENCY
INTRO
Adrenal insufficency occurs in 20% of
ICU pts
Induced by sepsis, hypovolaemia,
stress, drugs
Both high and low cortisol levels assoc.
with poor prognosis.
Higher levels assoc. with higher
APACHE and SOFA scores = poorer
prognosis
HPA INSUFFICIENCY
EXAMPLES
Cortisol > 1200 nmol/l in sepsis and resp
failure.
Cortisol > 745 nmol/l in ruptured AAA.
A ‘normal’ level for ICU patients cannot
be defined.
Use Synacthen and ACTH test.
HPA INSUFFICIENCY
CORTISOL SUPPLEMENTATION
Physiological doses of glucocorticoids
of 300 mg per day leads to
supraphysiological circulating cortisol
levels
In a multicentre trial, septic pts given
high dose cortisol – higher death rate
than placebo group.
HPA INSUFFICIENCY
CORTISOL SUPPLEMENTATION
Concept of “relative adrenal
insufficiency” and “low-dose” (ie, 100 to
300 mg per day) corticosteroid therapy.
Initial trials showed promising trends in
subgroups of patients with sepsis.
The beneficial effects were restricted to
improvements in hemodynamics and a
reduction in the need for vasopressor
therapy.
HPA INSUFFICIENCY
GENERAL CONCEPTS
The beneficial effect of steroids
remains unproven, and a conservative
approach is more prudent.
Clinician must rely on a clinical
assessment of the severity of the stress,
(evaluate misleading symptoms) to
estimate the adequacy of the measured
cortisol.
Clues of adrenal dysfunction, such as
unexplained eosinophilia
HPA INSUFFICIENCY
GENERAL CONCEPTS
Certain conditions - TB, Meningitis, Typhoid
fever, and PCP - the use of glucocorticoids
appears less controversial
Can be considered in selected highriskpatients, predominantly in septic shock
patients, while awaiting confirmatory results
of HPA testing.
Steroid therapy should be stopped if results
of HPA testing become available and do not
indicate the presence of adrenal
insufficiency
THE
END