UW. Thyroid: storm, euthyroid 03-03 (1) Flashcards
surg cases - storm, euthyroid
70 y/o + MI + undergoes emergency coronary artery bypass grafting. On the fourth postoperative day, he develops atrial flutter with a rapid ventricular response.
Thyroid function test results are as follows:
Free thyroxine (free T4) 1.4 ng/dL (normal: 0.9-2.4 ng/dL)
Triiodothyronine (T3), total 70 ng/dL (normal: 115-190 ng/dL)
Thyroid-stimulating hormone (TSH) 0.7 mU/L (normal: 0.5-5.0 mU/L)
Which of the following is the most likely etiology of this patient’s abnormal thyroid function tests?
EUTHYROID SICK SYNDROME
Euthyroid (Low T3 syndrome) table. risk factors?
its severe, acute illness.
severe acute illness
ICU admission
High-dose glucocorticoids therapy
Euthyroid (Low T3 syndrome) table. pathophysiology?
high circulating levels of glucocorticoids and inflammatory cytokines
Decr. peripheral conversion of T4 to T3
Euthyroid (Low T3 syndrome) table. Dx - early? arrows
Low T3, low free T3; normal TSH and T4
Euthyroid (Low T3 syndrome) table. Dx - late? arrows
Low T3,, low free T3 low TSH, low T4
Euthyroid (Low T3 syndrome) table. Mx?
observe without Tx
Follow up testin when patient had returned to baseline health
The most common pattern is low total and free T3 levels with normal T4 and TSH, often called euthyroid sick syndrome. If the underlying illness continues, T4 and TSH levels may eventually decrease.
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What rT3 levels?
INCREASED.
buvo prie surg grafikas, kur is pradziu normal, o paskui einant laikui + stiprejant undelying disease, tas rT3 levelis auga, o kitu mazeja (T3, TSH, T4)
Euthyroid. In general, thyroid function testing in hospitalized patients should be avoided; however, it may be necessary in certain circumstances (eg, to rule out hyperthyroidism in acute atrial fibrillation).
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When a euthyroid sick syndrome pattern is found, thyroid hormone supplementation does not improve clinical outcomes and is not indicated.
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when followup?
follow-up testing should be delayed until the patient has returned to baseline health.
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28 y/o + tachycardia in PACU. She was admitted for a right femur fracture following a motor vehicle collision and had an open reduction and internal fixation of the fracture. While in the recovery area, she began experiencing nausea and vomiting, and became anxious and agitated. The patient has no known medical problems. She drinks 1 or 2 glasses of wine on weekends. Temp. 39.4, BP160/90, pulse 148/min, RR 24/min. SpO2 98proc. On examination, the patient is delirious and has fine tremor. Mild lid lag is present. She has no muscle rigidity and deep-tendon reflexes are 2+ in the bilateral extremities. Laboratory results are as follows:
Hematocrit 30%
Sodium 135 mEq/L
Potassium 4.5 mEq/L
Bicarbonate 24 mEq/L
Blood urea nitrogen 32 mg/dL
Creatinine 1.2 mg/dL
Glucose 120 mg/dL
Creatine kinase, serum 176 U/L
Which of the following is the best next step in management of this patient?
THYROID FUNCTION TESTS AND PROPRANOLOL
UW. thyroid storm table. precipitating factors. 3
thyroid or nonthyroid surgery
acute illness (trauma, infection), childbirth
Acute iodine load (eg iodine contrast)
UW. thyroid storm table. CP?
Fever 40-41C
Tachy, HTN, congestive HF, arrhythmias (eg Afib)
Agitation, delirium, seizure, coma
Goiter, lid lag, warm and moist skin
Nausea, vomiting, diarrhea, jaundice
UW. thyroid storm table. Tx?
BAB = propranolol
PTU followed by iodine solution (SSKI = postassium iodine, cia toks sutrumpinimas buvo) - to decr hormone synthesis and release
Glucocorticoids (hydrocortisone = to decr T4 to T3 conversion)
Identify trigger and Tx, supportive care
Storm. precipitating factor + in patients with undiagnosed or inadequately treated hyperthyroidism.
Proposed mechanisms include a rapid increase in serum thyroid hormone levels or increased sensitivity to thyroid hormone.
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Storm - how make Dx?
Diagnosis is suspected clinically and confirmed by thyroid function studies documenting hyperthyroidism.
