Thyroid Disease in the Intensive Care Unit

Chapter 53 Thyroid Disease in the Intensive Care Unit



Annis Marney, MD, MSCI




1 What thyroid conditions require intensive care?




image Thyroid storm: Life-threatening thyrotoxicosis (accounts for 1%-2% of admissions for thyrotoxicosis and carries 20%-30% mortality)


image Myxedema coma: Life-threatening hypothyroidism (approximately 20% mortality)


Note: Nonthyroidal illness syndrome (NTIS), formerly known as euthyroid sick syndrome, is not life threatening.



2 How do you diagnose thyroid storm?


Thyroid storm often occurs in people with Graves disease who have stopped medication or whose condition is undiagnosed. In addition, a precipitating factor often exists such as severe infection, diabetic ketoacidosis, myocardial infarction (MI), cerebrovascular accident (CVA), heart failure, trauma, amiodarone therapy (short or long term), or a recent test involving iodinated contrast load (less than 6 weeks before presentation). It shares laboratory findings with thyrotoxicosis but is different from simple thyrotoxicosis in that it involves fever.


Clinical symptoms include the following:



image Fever >102° F (38.9° C) (hallmark): most consider this the sine qua non of thyroid storm


image Tachycardia


image Tachypnea


image Blood pressure not necessarily high or low


image Cardiac arrhythmias, heart failure, and/or ischemia: common


image Nausea, vomiting, diarrhea


image Agitation, tremulousness, delirium


image Jaundice: a particularly worrisome sign


Laboratory findings include suppressed (undetectable, not just low) thyroid-stimulating hormone (TSH) and elevated serum total thyroxine (T4) (TT4), free T4 (FT4), total triiodothyronine (T3) (TT3), and free T3 (FT3).



3 How do you treat thyroid storm?


Use common sense. First, support the patient as you would any critically ill patient and be sure to initiate cardiac monitoring. Next, reduce thyroid hormone production with thioureas. Finally, stop release of preformed hormone by adding iodide. Simultaneously with these measures give β-blockade to slow heart rate and reduce conversion of T4 to T3 (see Table 53-1).


Table 53-1 Supportive Care and Specific Medications for Thyroid Storm















































































Intervention and mechanism of action Dose Route
Supportive care
Isotonic fluids Patient specific IV
Oxygen Patient specific Nasal cannula if stable enough
Cooling blanket   Topical
Acetaminophen or other antipyretics Adult dosing Oral, rectal, or NG
Thioureas: reduce thyroid hormone production
Propylthiouracil 150 mg every 6 hr Oral, rectal, or NG
Methimazole (Tapazole) 20 mg every 8 hr Oral, rectal, or NG
Iodide: reduce hormone production and T4 to T3 conversion 2-4 hr after starting thioamide (above)
Saturated solution of potassium iodide 5 drops (250 mg) twice daily Oral
Iopanoic acid 0.5 g twice daily Oral or IV
Iohexol 0.6 g (2 mL of Omnipaque 300) twice daily IV
β-Blockade: reduce heart rate and reduce conversion of T4 to T3
Propranolol 40-80 mg every 6 hr Oral
Propranolol 0.5-1.0 mg over 10 min every 3 hr IV
Esmolol (especially if patient has asthma and needs β1-selective agent) 0.25-0.5 mg/kg bolus followed by 0.05-0.1 mg/kg/min infusion IV
Glucocorticoids: support circulation, supplement glucocorticoid reserve because of increased metabolism and reduced half-life with thyrotoxicosis, and reduce T4 to T3 conversion
Dexamethasone 2 mg every 6 hr × 48 hr, then taper dose rapidly Oral or IV
Hydrocortisone 100 mg every 8 hr × 48 hr, then taper dose rapidly IV
Resin binders: remove T4 in the gut to reduce enterohepatic circulation of free T4
Cholestyramine or colestipol 20-30 g daily Oral or NG

IV, Intravenous; NG, nasogastric.

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Jul 6, 2016 | Posted by in CRITICAL CARE | Comments Off on Thyroid Disease in the Intensive Care Unit

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