Metabolic Illness and Endocrinopathies

Metabolic Illness and Endocrinopathies

Andrew J. Young, MD1 and Therese M. Duane, MD2

1 Department of Trauma, Critical Care and Burn, The Ohio State University, Columbus, OH, USA

2 TCU & UNTHSC School of Medicine, Department of Surgery, Texas Health Resources, Fort Worth, TX, USA

  1. A 54‐year‐old obese woman with a history of end‐ stage renal disease on dialysis, atrial fibrillation on warfarin, and diabetes mellitus is admitted to the surgical intensive care unit after debridement of necrotic tissue from her right leg caused by calci phylaxis. Anesthesia signs out that there was difficulty coming off vasopressor support at the conclusion of the case. She is intubated and sedated. The dressings are clean and dry. You note other lesions on her left leg that appear necrotic. You have begun to reconcile her medications. Which medication should not be continued?

    1. Vancomycin
    2. Phenylephrine
    3. Oxycodone
    4. Filgrastim
    5. Warfarin

    Calciphylaxis is a difficult disease to treat. It typically occurs in patients with chronic kidney disease. Patients typically die from sepsis due to the wounds caused by calciphylaxis. The etiology of this disease has yet to be elucidated, but there are known risk factors. Medications that can cause this disease include warfarin, calcium, vitamin D, iron, and recombinant PTH. Thus, these should be stopped once the diagnosis of calciphylaxis is made. Answer E is correct. The other medications have not been associated with increased risk of calciphylaxis.

    Answer: E

    McCarthy JT, el‐Azhary RA, Patzelt MT, et al. Survival, risk factors, and effect of treatment in 101 patients with calciphylaxis. Mayo Clinic Proceedings 2016; 91(10):1384–1394. doi:10.1016/j.mayocp.2016.06.025

    Nigwekar SU, Thadhani R, and Brandenburg VM . Calciphylaxis. The New England Journal of Medicine 2018; 378(18):1704–1714. doi:10.1056/NEJMra1505292

  2. A 22‐year‐old man is admitted to the intensive care unit following a motorcycle collision. He was not wearing a helmet and suffered several small intracranial hemorrhages. It has been difficult maintaining adequate cerebral perfusion pressure although he has not required vasopressors. He has been receiving intravenous fluid, as well as enteral nutrition. On post‐trauma day 4, his sodium is noted to be 156 mEq/L, and his urine output has increased to 120 mL/hr overnight. What is the best course of action at this time?

    1. Change parenteral fluids to 0.9% normal saline.
    2. Change parenteral fluids to 5% dextrose in water.
    3. Add free water to his nasogastric tube.
    4. Begin levothyroxine 100 mcg/daily.
    5. Replace urine output milliliter per milliliter every 4 hours to maintain euvolemia.

    This patient has diabetes insipidus (DI), which is a deficiency of antidiuretic hormone (ADH). There are two types of DI – central and nephrogenic. This patient most likely has central DI from his brain injury. Administration of exogenous ADH helps differentiate between the two types of DI. If the patient responds to the ADH (urine out decreases and becomes more concentrated), then it is central DI. If the patient does not respond to the exogenous ADH, then it is nephrogenic. Initial treatment consists of increasing free water to try and correct the hyperosmolarity. There may also be elevated serum potassium and calcium. Free water administration may also correct these abnormalities. Initial administration of free water should occur enterally if access is available, thus answer C is correct, otherwise the next best choice is answer B. Answer A is incorrect because this may worsen the hypernatremia. This patient does not have thyroid insufficiency, so answer d is incorrect. While this patient may become hypovolemic due to the high urine output, there is no current recommendation for a specific fluid replacement protocol (answer E).

    Answer: C

    Capatina C, Paluzzi A, Mitchell R, et al. Diabetes insipidus after traumatic brain injury. Journal of Clinical Medicine 2015; 4(7):1448–1462. doi:10.3390/jcm4071448

  3. A 63‐year‐old woman is admitted to the surgical intensive care unit following a sigmoid resection and Hartmann’s procedure for diverticulitis complicated by feculent peritonitis. She is on two vasopressors and has received adequate fluid resuscitation. Her mean arterial blood pressure readings have been consistently above 65 mmHg and is making adequate urine. Should steroids be started and if so which one?

    1. Hydrocortisone intermittent dosing
    2. Hydrocortisone continuous infusion
    3. Solumedrol
    4. Dexamethasone
    5. No steroids

    There is still much debate regarding steroids in septic shock; however, the current surviving sepsis guidelines recommend against start corticosteroids. In a patient who is responsive to fluid resuscitation and vasopressors, steroids should not be empirically started.

    Answer: E

    Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine 2017; 43(3):304–77. doi:10.1007/s00134‐017‐4683‐6

    Venkatesh B, Finfer S, Cohen J, et al. Adjunctive glucocorticoid therapy in patients with septic shock. The New England Journal of Medicine 2018; 378(9):797–808. doi:10.1056/NEJMoa1705835

  4. A 58‐year‐old man has been admitted to the intensive care unit following a motor vehicle collision in which he sustained multiple long bone fractures, a colonic injury which was resected and a Hartmann’s procedure was performed, and several small intraparenchymal hemorrhages. He had no known medical problems prior to this accident per his family. He is currently intubated with an orogastric tube. You wish to begin enteral feeds. At the same time, you order regular blood glucose checks with associated sliding scale insulin. The negative effects of hyperglycemia in critical illness include which of the following?

    1. Worse outcomes in patients with traumatic brain injury
    2. Hypercoagulable state
    3. Poor gut motility
    4. Risk factor for infection
    5. All of the above

    While the exact target range for appropriate blood glucose level has had much debate, there is consensus that hyperglycemia can cause harm. Detrimental effects include worse outcomes in patients with traumatic brain injury, decreased gut motility potentially leading to bacterial overgrowth and translocation, and is a risk factor for infection (answer E).

    Answer: E

    Brealey D and Singer M . Hyperglycemia in critical illness: a review. Journal of Diabetes Science and Technology 2009; 3(6):1250–1260. doi:10.1177/193229680900300604

    Krinsley JS . Glycemic control in the critically ill: what have we learned since NICE‐SUGAR? Hospital Practice 2015; 43(3):191–197. doi:10.1080/21548331.2015.1066227

  5. A 54‐year‐old woman has been in the intensive care unit for the last week following a motor vehicle crash. She sustained multiple orthopedic injuries including bilateral femur fractures and a right humorous fracture. Neurologically, she has not had a Glasgow Coma Score (GCS) higher than 6 since her admission. She has been diagnosed with diffuse axonal injury (DAI). Her blood sugars have been slowly increasing over the last week with the most recent checks consistently over 200 mg/dL. A sliding scale insulin regiment is begun. What diagnosis in her past medical history might guide your insulin therapy?

    1. Hypertension
    2. Steroid use
    3. Diabetes mellitus
    4. Inflammatory bowel disease requiring immunomodulators
    5. Hypothyroid

    Tight blood glucose control was first promulgated in 2001 with the publication of a trial that demonstrated that “tight” (80–110 mg/dL) blood glucose control improved mortality in the intensive care unit. Subsequent studies failed to reproduce this, and this was further debunked in 2009 with the publication of the NICE‐SUGAR trial, which found that with moderate blood glucose control (a goal of <180mg/dL) have improved outcomes. However, later studies found that in patients with a history of diabetes, a higher blood glucose target was associated with better outcomes.

    Answer: C

    Finfer S, Bellomi R, Blair D, et al. Intensive versus conventional glucose control in critically ill patients. The New England Journal of Medicine 2009; 360(13):1283–1297. doi:10.1056/NEJMoa0810625

    Krinsley JS, Egi M, Kiss A, et al. Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study. Critical Care 2013; 17(2):R37. doi:10.1186/cc12547

  6. A 32‐year‐old woman is admitted to the intensive care unit following a right robot‐assisted adrenalectomy for an adrenal adenoma. A few hours postoperatively, she experiences hypotension, nausea, emesis, hypoglycemia, and confusion. The operative team tells you it was a glucocorticoid‐secreting tumor that they removed. Which medication should she have been placed on prior to surgery?

    1. Metoprolol and phenoxybenzamine
    2. Hydrocortisone
    3. Prazosin
    4. Furosemide
    5. Oxymetazoline

    The patient is experiencing an Addisonian crisis (primary adrenal insufficiency), which consists of hypotension, vomiting, diarrhea, hyperkalemia, hypercalcemia, fever, syncope, lethargy, and abdominal pain. Patients should be placed on replacement therapy prior to adrenalectomy and continue with therapy afterwards to prevent hypocortisolism. Therapy includes treatment for both mineralocorticoid and glucocorticoid deficiency (fludrocortisone and hydrocortisone, respectively). When a patient is in crisis, they require high‐dose steroid therapy (hydrocortisone 100 mg every 8 hours), fluid resuscitation, electrolyte correction, and intensive care monitoring.

    Answer: B

    Charmandari E, Nicolaides NC, and Chrousos GP . Adrenal insufficiency. The Lancet. 2014; 383(9935):2152–2167. doi:10.1016/S0140‐6736(13)61684‐0

  7. An 81‐year‐old woman arrives in the trauma bay in January following an unwitnessed ground level fall at her nursing home. Her Glasgow Coma Scale (GCS) is 8. On secondary exam, a heart rate of 42, blood pressure of 83/40, respiratory rate of 8, and temperature of 31 °C were found. A chest X‐ray reveals a consolidation of the right lower lobe of her lung. She is intubated, resuscitated, and broad‐spectrum antibiotics for a presumed pneumonia are begun, and she is admitted to the ICU. Additional imaging reveals only the right lung finding. Her TSH level is checked and found to be high. Myxedema coma is suspected. What is the best course of action?

    1. Begin intravenous levothyroxine therapy alone.
    2. Begin intravenous T4, T3, and hydrocortisone therapy.
    3. Slowly correct electrolyte abnormalities prior to starting any hormone therapy.
    4. Treatment of the infection with antibiotics alone is sufficient to correct any thyroid abnormalities.
    5. Recheck TSH after normothermia is achieved before making the diagnosis of myxedema coma.

    Myxedema coma is a rare phenomenon, so one must have a high index of suspicion in order to make the diagnosis. The mortality rate is high given that there is usually a precipitating event (infection in this case), which can cloud the diagnosis. High TSH in the setting of profound hypothermia and unconsciousness should lead one to suspect the diagnosis. Admission to an intensive care unit is recommended along with concomitant treatment of respiratory failure, electrolyte abnormalities, vasoplegia, and cardiac depression. Treatment should focus on airway control due to patients having a mixed hypoxic and hypercapnic picture of respiratory failure. There is controversy surrounding whether or not to give T3 or T4, thus some recommend giving both. T3 will have a fast onset, while T4 will have a slow, steady onset depending on the patient’s deiodinase activity.

    Answer: B

    Wartofsky L and Klubo‐Gwiezdzinska J . Myxedema coma. In: Luster M, Duntas LH, Wartofsky L, eds. The Thyroid and Its Diseases: A Comprehensive Guide for the Clinician. Springer International Publishing; 2019:281–292. doi:10.1007/978‐3‐319‐72102‐6_20

  8. A 28‐year‐old woman underwent an uncomplicated laparoscopic appendectomy for acute appendicitis overnight. The next morning she is noted to be confused, hypertensive, tachycardic to 134, febrile to 102, complaining of chest pain, and difficulty breathing with new onset pedal edema and rales. A workup ensues. She is transferred to the intensive care unit and broad‐spectrum antibiotics are started over the concern for sepsis. On review of her medical problems, it is noted that she had a history of Graves’ disease for which she takes methimazole. It is unknown when she received her last dose. The most appropriate medication to give next is:

    1. Her home methimazole dose, 25 mg PO

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Metabolic Illness and Endocrinopathies

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