Myxedema coma medical therapy: Difference between revisions
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{{CMG}} ; {{AE}} {{ADG}} | {{CMG}} ; {{AE}} {{ADG}} | ||
==Overview== | ==Overview== | ||
All the patients with myxedema coma should be admitted to ICU and treatment must be started as quickly as possible. Given the clinical suspicion of myxedema coma, initiate replacement therapy without waiting for laboratory results. The empirical use of glucocorticoids should be part of the initial therapeutic protocol as severe hypothyroidism induces a lower adrenal response to stress. Administration of glucocorticoids is independent of whether or not there is simultaneous adrenal insufficiency. Since thyroid hormone speeds up metabolism of cortisol and its plasma levels may be decreased in the presence of adrenal insufficiency, the glucocorticoids should always be given prior to thyroid replacement because otherwise they could precipitate an adrenal crisis. Hydrocortisone must be given in doses of, 50- 100 mg intravenously (IV) every 6-8 h for 7 to 10 days or until hemodynamically stabilizes the patient. Identify and properly treat the precipitating factor. | All the patients with myxedema coma should be admitted to [[Intensive care unit|ICU]] and treatment must be started as quickly as possible. Given the clinical suspicion of myxedema coma, initiate replacement therapy without waiting for laboratory results. The empirical use of [[glucocorticoids]] should be part of the initial therapeutic protocol as severe [[hypothyroidism]] induces a lower [[Adrenal Gland|adrenal response]] to [[stress]]. Administration of [[glucocorticoids]] is independent of whether or not there is simultaneous [[adrenal insufficiency]]. Since [[thyroid hormone]] speeds up [[metabolism]] of [[cortisol]] and its [[plasma]] levels may be decreased in the presence of [[adrenal insufficiency]], the [[glucocorticoids]] should always be given prior to [[Thyroid hormone|thyroid replacement]] because otherwise they could precipitate an [[Adrenal crisis|adrenal crisis.]] [[Hydrocortisone]] must be given in doses of, 50- 100 mg intravenously (IV) every 6-8 h for 7 to 10 days or until [[hemodynamically]] stabilizes the patient. Identify and properly treat the precipitating factor. | ||
==Medical Therapy== | ==Medical Therapy== | ||
Treatment of myxedema coma should be performed in an Intensive Care Unit (ICU) and start with as quickly as possible. <ref name="pmid7808091">{{cite journal |vauthors=Jordan RM |title=Myxedema coma. Pathophysiology, therapy, and factors affecting prognosis |journal=Med. Clin. North Am. |volume=79 |issue=1 |pages=185–94 |year=1995 |pmid=7808091 |doi= |url=}}</ref><ref name="pmid17712058">{{cite journal |vauthors=Kwaku MP, Burman KD |title=Myxedema coma |journal=J Intensive Care Med |volume=22 |issue=4 |pages=224–31 |year=2007 |pmid=17712058 |doi=10.1177/0885066607301361 |url=}}</ref><ref name="pmid11130234">{{cite journal |vauthors=Wall CR |title=Myxedema coma: diagnosis and treatment |journal=Am Fam Physician |volume=62 |issue=11 |pages=2485–90 |year=2000 |pmid=11130234 |doi= |url=}}</ref><ref name="pmid28825577">{{cite journal |vauthors=Rizzo LFL, Mana DL, Bruno OD, Wartofsky L |title=[Myxedema coma] |language=Spanish; Castilian |journal=Medicina (B Aires) |volume=77 |issue=4 |pages=321–328 |year=2017 |pmid=28825577 |doi= |url=}}</ref> | Treatment of myxedema coma should be performed in an Intensive Care Unit ([[ICU]]) and start with as quickly as possible. <ref name="pmid7808091">{{cite journal |vauthors=Jordan RM |title=Myxedema coma. Pathophysiology, therapy, and factors affecting prognosis |journal=Med. Clin. North Am. |volume=79 |issue=1 |pages=185–94 |year=1995 |pmid=7808091 |doi= |url=}}</ref><ref name="pmid17712058">{{cite journal |vauthors=Kwaku MP, Burman KD |title=Myxedema coma |journal=J Intensive Care Med |volume=22 |issue=4 |pages=224–31 |year=2007 |pmid=17712058 |doi=10.1177/0885066607301361 |url=}}</ref><ref name="pmid11130234">{{cite journal |vauthors=Wall CR |title=Myxedema coma: diagnosis and treatment |journal=Am Fam Physician |volume=62 |issue=11 |pages=2485–90 |year=2000 |pmid=11130234 |doi= |url=}}</ref><ref name="pmid28825577">{{cite journal |vauthors=Rizzo LFL, Mana DL, Bruno OD, Wartofsky L |title=[Myxedema coma] |language=Spanish; Castilian |journal=Medicina (B Aires) |volume=77 |issue=4 |pages=321–328 |year=2017 |pmid=28825577 |doi= |url=}}</ref> | ||
===Replacement Therapy=== | ===Replacement Therapy=== | ||
:*Preferred regimen (1)-levothyroxine (LT4)200-400 μg in IV bolus in the first 48 hours, followed by one dose more physiological 50-100 μg IV daily until you can administer orally. | :*Preferred regimen (1)-[[levothyroxine]] (LT4)200-400 μg in IV bolus in the first 48 hours, followed by one dose more physiological 50-100 μg IV daily until you can administer orally. | ||
:**Note-some propose to start with larger doses of 300-500 μg | :**Note-some propose to start with larger doses of 300-500 μg | ||
:**Note-To avoid the risk of cardiac complications continuous cardiac monitoring with dose reduction of thyroid hormone to see ischemic changes or arrhythmias. | :**Note-To avoid the risk of cardiac complications continuous cardiac monitoring with dose reduction of [[thyroid hormone]] to see ischemic changes or [[arrhythmias]]. | ||
:*Alternative regimen (1)-10 μg of | :*Alternative regimen (1)- 10 μg of [[T3]] in IV bolus with the dose of [[T4]] and continue with 10 μg every 8-12 hs along the [[T4]] until recovery. '''OR''' | ||
:*Alternative regimen (2)- | :*Alternative regimen (2)- [[T4]] + [[T3]] 5-20 μg IV bolus as loading dose, followed by 2.5-10 μg every 8 h | ||
===Supportive=== | ===Supportive=== | ||
*Broad-spectrum antibiotics should be started immediately given the high incidence of infections in comatose patients. | *Broad-spectrum [[antibiotics]] should be started immediately given the high incidence of [[infections]] in comatose patients. | ||
*Ventilation is initiated to reduce CO2 retention and respiratory acidosis. | *Ventilation is initiated to reduce [[CO2]] retention and [[respiratory acidosis]]. | ||
*Hypothermia must be treated using passive methods(blankets) since they can generate greater vasodilation. Avoid using rewarming techniques. | *[[Hypothermia]] must be treated using passive methods(blankets) since they can generate greater [[vasodilation]]. Avoid using rewarming techniques. | ||
*The treatment of hypotension should be energetic by evaluating the best option, either volume replenishment or drug pressures with dynamic monitoring. | *The treatment of [[hypotension]] should be energetic by evaluating the best option, either volume replenishment or drug pressures with dynamic monitoring. | ||
*Hyponatremia and hypoglycemia can be corrected by administering electrolytes and dextrose. | *[[Hyponatremia]] and [[hypoglycemia]] can be corrected by administering [[Electrolyte|electrolytes]] and [[dextrose]]. | ||
**Correction of hyponatremia requires low hypertonic saline solution (50-100 ml | **Correction of [[hyponatremia]] requires low [[Hypertonic|hypertonic saline]] solution (50-100 ml [[Normal saline|NS]] al 3%), sufficient to increase the [[sodium]] concentration at about 2 mEq / l in the initial course of treatment, followed by an IV bolus of [[furosemide]] 40 to 120 mg promote watery [[diuresis]]. | ||
**Rapid correction of the | **Rapid correction of the [[hyponatremia]] can cause a complication [[osmotic demyelination syndrome]] ([[central pontine myelinolysis]]). | ||
**After reaching a sodium level greater than 120 mEq / l, the water restriction is sufficient to completely normalize the | **After reaching a sodium level greater than 120 mEq / l, the water restriction is sufficient to completely normalize the [[hyponatremia]]. | ||
*Another therapeutic option, is to administer an antidiuretic hormone antagonist such as tolvaptan or conivaptan. | *Another therapeutic option, is to administer an [[antidiuretic hormone]] antagonist such as [[tolvaptan]] or [[conivaptan]]. | ||
{| class="wikitable" | {| class="wikitable" | ||
!Condition | !Condition | ||
!Management | !Management | ||
|- | |- | ||
| | |Reduced cortisol | ||
| | |Iv [[hydrocortisone]] 200-400 mg daily | ||
|- | |- | ||
|Hypoventilation | |[[Hypoventilation]] | ||
|Intubation and mechanical ventilation | |Intubation and [[mechanical ventilation]] | ||
|- | |- | ||
|Hypothermia | |[[Hypothermia]] | ||
|Blankets(no active rewarming) | |Blankets(no active rewarming) | ||
|- | |- | ||
|Hyponatremia | |[[Hyponatremia]] | ||
|Fluid restriction | |Fluid restriction | ||
|- | |- | ||
|Hypotension | |[[Hypotension]] | ||
| | |Volume expansion with crystalloid or whole blood | ||
|- | |- | ||
|Hypoglycemia | |[[Hypoglycemia]] | ||
| | |[[Glucose]] administration | ||
|} | |} | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Revision as of 14:52, 18 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
All the patients with myxedema coma should be admitted to ICU and treatment must be started as quickly as possible. Given the clinical suspicion of myxedema coma, initiate replacement therapy without waiting for laboratory results. The empirical use of glucocorticoids should be part of the initial therapeutic protocol as severe hypothyroidism induces a lower adrenal response to stress. Administration of glucocorticoids is independent of whether or not there is simultaneous adrenal insufficiency. Since thyroid hormone speeds up metabolism of cortisol and its plasma levels may be decreased in the presence of adrenal insufficiency, the glucocorticoids should always be given prior to thyroid replacement because otherwise they could precipitate an adrenal crisis. Hydrocortisone must be given in doses of, 50- 100 mg intravenously (IV) every 6-8 h for 7 to 10 days or until hemodynamically stabilizes the patient. Identify and properly treat the precipitating factor.
Medical Therapy
Treatment of myxedema coma should be performed in an Intensive Care Unit (ICU) and start with as quickly as possible. [1][2][3][4]
Replacement Therapy
- Preferred regimen (1)-levothyroxine (LT4)200-400 μg in IV bolus in the first 48 hours, followed by one dose more physiological 50-100 μg IV daily until you can administer orally.
- Note-some propose to start with larger doses of 300-500 μg
- Note-To avoid the risk of cardiac complications continuous cardiac monitoring with dose reduction of thyroid hormone to see ischemic changes or arrhythmias.
- Preferred regimen (1)-levothyroxine (LT4)200-400 μg in IV bolus in the first 48 hours, followed by one dose more physiological 50-100 μg IV daily until you can administer orally.
Supportive
- Broad-spectrum antibiotics should be started immediately given the high incidence of infections in comatose patients.
- Ventilation is initiated to reduce CO2 retention and respiratory acidosis.
- Hypothermia must be treated using passive methods(blankets) since they can generate greater vasodilation. Avoid using rewarming techniques.
- The treatment of hypotension should be energetic by evaluating the best option, either volume replenishment or drug pressures with dynamic monitoring.
- Hyponatremia and hypoglycemia can be corrected by administering electrolytes and dextrose.
- Correction of hyponatremia requires low hypertonic saline solution (50-100 ml NS al 3%), sufficient to increase the sodium concentration at about 2 mEq / l in the initial course of treatment, followed by an IV bolus of furosemide 40 to 120 mg promote watery diuresis.
- Rapid correction of the hyponatremia can cause a complication osmotic demyelination syndrome (central pontine myelinolysis).
- After reaching a sodium level greater than 120 mEq / l, the water restriction is sufficient to completely normalize the hyponatremia.
- Another therapeutic option, is to administer an antidiuretic hormone antagonist such as tolvaptan or conivaptan.
| Condition | Management |
|---|---|
| Reduced cortisol | Iv hydrocortisone 200-400 mg daily |
| Hypoventilation | Intubation and mechanical ventilation |
| Hypothermia | Blankets(no active rewarming) |
| Hyponatremia | Fluid restriction |
| Hypotension | Volume expansion with crystalloid or whole blood |
| Hypoglycemia | Glucose administration |
References
- ↑ Jordan RM (1995). "Myxedema coma. Pathophysiology, therapy, and factors affecting prognosis". Med. Clin. North Am. 79 (1): 185–94. PMID 7808091.
- ↑ Kwaku MP, Burman KD (2007). "Myxedema coma". J Intensive Care Med. 22 (4): 224–31. doi:10.1177/0885066607301361. PMID 17712058.
- ↑ Wall CR (2000). "Myxedema coma: diagnosis and treatment". Am Fam Physician. 62 (11): 2485–90. PMID 11130234.
- ↑ Rizzo L, Mana DL, Bruno OD, Wartofsky L (2017). "[Myxedema coma]". Medicina (B Aires) (in Spanish; Castilian). 77 (4): 321–328. PMID 28825577. Vancouver style error: initials (help)