From Where? Rochester, NY

Transcription

1

2

3 From Where? Rochester, NY

4 3 Days of Sunshine Annually Invented SAD Lights

5 Disclosures I have no financial disclosures The feds want their money back The only bad question...

6 Objectives Review endocrine fundamentals Highlight four ICU endocrine disorders DM, CIRCI, hypothyroid, hyperthyroid Discuss pathophys of alcohol withdrawal Review the treatment options

7 Endocrinopathy Easy in the ICU Call for help thyroid-and-beyond

8 Endocrine Fundamentals Endocrine- hormones into bloodstream Hormones

9 Hormones

10 Endocrine Fundamentals Endocrine- hormones into bloodstream Hormones Act on target organs Signaling for long distances Prolonged duration Delayed onset

11 The Pituitary Gland Master gland Controls other glands

12 Thyroid The Rest Controls metabolism Parathyroid Ca 2+ homeostasis Thymus T lymphocyte development Pancreas Glucagon( ), insulin(β), somastatin(δ) Pineal Internal clock Adrenal Norepi and epi Aldosterone Cortisol Androgens Ovaries and testes Sexual development

13 Diabetes

14 Diabetes 98% easy Insulin pump? Acute pancreatitis Shock liver Feeding? Steroids

15 Adrenal Dysfunction Primary stress response organ Hemodynamic instability Volume loss Adrenal insufficiency Caused centrally or peripherally Present in up to 60% of ICU patients Annane D, Maxime V, Ibrahim F, et al. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med. 2006; 174:

16 Causes of Adrenal Dysfunction Exogenous steroid discontinuation Inflammatory cytokines Bacterial toxins Medications (etomidate) Adrenal hemorrhage Increased cortisol metabolism

17 Primary Symptom and Workup Hypotension ACTH(adrenocorticotropic) stim test Draw serum cortisol, admin Cosyntropin Draw serum cortisol in 60 mins Expect cortisol to double to ~50 ug/dl If cortisol < 9 or random < 10, + test Will results change your plan Annane, D, Pastores, S, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): SCCM and ESICM Critical Care Medicine: Dec 2017; Volume 45(2)

18 Stress Dose Steroid Options Hydrocortisone(gluc + mineralo) Dexamethasone(gluc only) Methylprednisolone(mostly gluc) Prednisone(gluc + mineralo) PO only Fludrocortisone(mineralo) PO only D/C with BP resolution, wean?

19 Critical Illness-Related Corticosteriod Insufficiency(CIRCI) SDS Guidelines Part I 250µg Stim Test: Yes (poor) Sepsis shock: No (mod) Sepsis + shock: Yes (poor) Duration: > 3 days (poor) ARDS: Yes (mod) Major trauma: No (poor) Part II CAP: Yes, 5-7 days (mod) Flu: No (very poor) Meningitis: Yes (poor) CABG: Yes (mod) Arrest: Yes (poor) Annane, D, Pastores, S, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): SCCM and ESICM Critical Care Medicine: Dec 2017; Volume 45(2) Pastores S, Annane, D, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part II): SCCM and ESICM Critical Care Medicine: Jan 2018; Volume 46(1)

20 Thyroid Dysfunction Walking into the mine field T 4 - secreted by thyroid gland T 3 - active form Both are highly protein bound Abnormal in 70 % hospital patients Severely confounded in ICU Adler S, Wartofsky L. The Nonthyroidal Illness Syndrome. Endocrinol Metab Clin N Am. 36 (2007), pp

21 Why Confounded Plasma protein binding in acute illness Free T 4 levels are checked TSH is time dependent Distinguish between primary and secondary disorders

22 Thyrotoxicosis Primary hyperthyroidism Autoimmune thyroiditis Amiodarone New onset AF Tremulousness Treated with beta blockers and methimazole

23 Thyroid Storm Precipitated by surgery Hyperthermia Delirium Hyperdynamic heart Seizures Death

24 Diagnosis and Treatment TSH is usually undetectable Beta blockade Traditionally propranolol Metoprolol (more selective) Esmolol gtt for severe cases Thyroid suppression Propylthiouracil (PTU) or iodine

25 Hypothyroidism Free T 4 levels are low Hashimoto s thyroiditis Surgical excision or radioiodine Enlarged cardiac silhouette Pericardial effusions Lithium

26 Myxedema Coma Profound edema Intradermal build up of proteins Hypothermia Altered LOC

27 Treatment Levothyroxine PO preferred Dose adjustments weekly Levothyroxine IV for myxedema Wait 3-5 days to restart in ICU

28 Melatonin Reduce sedation needs Restores circadian rhythm No clear recommendations RCTs are pending Mistraletti G, Umbrello M, Sabbatini G, et al. Melatonin reduces the need for sedation in ICU patients: a RCT. Minerva Anesthesiol Dec; 81(12):

29 Alcohol Withdrawal Reduced GABA A stimulation Reduced NMDA inhibition Leads to CNS excitation Agitation Delirium Seizures

30 Wernicke s Encephalopathy Low thiamine Poor dietary intake Administer IV dextrose thiamine + D50 = Wernicke s Extreme B-vitamin depletion Prophylaxis with thiamine

31 Korsakoff s Syndrome Low thiamine Korsakoff s psychosis Poor longterm prognosis IV thiamine, nutrition, hydration Positive treatment can take years

32 Alcohol Withdrawal Timeline 6-8 hours Anxiety, tremulousness, nausea Professionals will seize hours Hallucinations

33 Delirium Tremens Usually hours Fever Hyperadrenergic Agitation Altered LOC

34 Care Plan Rule out other etiologies Quiet environment Free from stimulation May need restraints Floor vs ICU

35 ICU Admission Criteria Broadly accept Significant comorbidities High doses of meds Electrolyte problems Concern for GI bleeding Withdrawal related seizures al%20treatment&rank=1~143&source=see_link

36 NV Tremor Sweats Anxiety Agitation CIWA Auditory, tactile, visual disturbances Headache Altered LOC

37 Benzodiazepines Start to treat for CIWA > 10 Gain control with frequent dosing Every 10 minutes Develop a maintenance plan Insist on CIWA scoring Avoid unnecessary medications

38 Galton s Rule for Benzos in ICU Only two options Seizures Alcohol withdrawal Apply liberally PO diazepam IV lorazepam

39 Phenobarbital Work synergistically with benzos Work OK independently Dosing is 65 mg, 130 mg, 260 mg Every minutes Makes anecdotal sense with GABA A May require intubation

40 Dexmedetomidine Infusion Textbook dose mcg/kg/hr Not a respiratory depressant Hemodynamic instability(> 0.7) Tolerance in days Lacking any significant evidence ICU admission?

41 Propofol Mechanism of action Strong respiratory depressant Hemodynamic instability May require intubation Treatment vs anesthesia?

42 Ethanol Infusion NOT recommended Poor titratability End organ damage Metabolic instability

43 Review the Objectives Review endocrine fundamentals Highlight four ICU endocrine disorders Discuss pathophysiology of alcohol withdrawal Review the treatment options

44 Thanks for Inviting Me SAD Treatment Plan

45

46