From Where?

Rochester, NY

3 Days of Sunshine Annually

Invented SAD Lights

Disclosures

I have no financial

disclosures

The feds want their

money back

The only bad

question . . .

ObjectivesReview endocrine fundamentals

Highlight four ICU endocrine disorders

DM, CIRCI, hypothyroid, hyperthyroid

Discuss pathophys of alcohol withdrawal

Review the treatment options

http://medicscientist.com/hyperthyroidism-thyrotoxicosis-causes-symptoms-diagnosis

https://www.alcoholismrehab.org/alcoholism/how-many-heavy-drinkers-develop-alcoholism/s

Endocrinopathy

Easy in the ICU

Call for help

https://www.staples-3p.com/s7/is/ http://www.lovelace.com/news/blog/endocrinology-–-thyroid-and-beyond

Endocrine Fundamentals

Endocrine- hormones into bloodstream

Hormones

Hormones

Endocrine Fundamentals

Endocrine- hormones into bloodstream

Hormones

Act on target organs

Signaling for long distances

Prolonged duration

Delayed onset

https://www.theodysseyonline.com/20-things-to-do-when-your-bored

The Pituitary Gland

Master gland

Controls other glands

https://www.nzgp-webdirectory.co.nz/Pituitary+Hormones.html

The RestThyroid

Controls metabolism

Parathyroid

Ca2+ homeostasis

Thymus

T lymphocyte development

Pancreas

Glucagon(⍺), insulin(Β),

somastatin(δ)

PinealInternal clock

Adrenal

Norepi and epi

Aldosterone

Cortisol

Androgens

Ovaries and testes

Sexual development

https://en.wikipedia.org/wiki/Endocrine_system

Diabetes

https://thenorwichradical.com/2016/09/07/immigration-the-elephant-in-the-room/

Diabetes

98% easy

Insulin pump?

Acute pancreatitis

Shock liver

Feeding?

Steroids …https://nutrition.abbott/au/tube-feeding

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: 1319-1326.

Causes of Adrenal Dysfunction

Exogenous steroid discontinuation

Inflammatory cytokines

Bacterial toxins

Medications (etomidate)

Adrenal hemorrhage

Increased cortisol metabolism

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 2017. Critical Care Medicine: Dec 2017; Volume 45(2). 2078-2088.

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?

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)

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 2017. Critical Care Medicine: Jan 2018; Volume 46(1). 146-148.

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 2017. Critical Care Medicine: Dec 2017; Volume 45(2). 2078-2088.

Thyroid Dysfunction

Walking into the mine field

T4- secreted by thyroid gland

T3- 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. 657-672.

Why ConfoundedPlasma protein binding in acute illness

Free T4 levels are checked

TSH is time dependent

Distinguish between primary and secondary

disorders

https://clinicalgate.com/thyroid-abnormalities/

Thyrotoxicosis

Primary hyperthyroidism

Autoimmune thyroiditis

Amiodarone

New onset AF

Tremulousness

Treated with beta blockers and

methimazole

Thyroid Storm

Precipitated by surgery

Hyperthermia

Delirium

Hyperdynamic heart

Seizures

Death

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

Hypothyroidism

Free T4 levels are low

Hashimoto’s thyroiditis

Surgical excision or radioiodine

Enlarged cardiac silhouette

Pericardial effusions

Lithium

Myxedema Coma

Profound edema

Intradermal build up of proteins

Hypothermia

Altered LOC

https://www.pinterest.com/pin/16325617382599086/

Treatment

Levothyroxine PO preferred

Dose adjustments weekly

Levothyroxine IV for myxedema

Wait 3-5 days to restart in ICU

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. 2015 Dec; 81(12):1298-1310.

http://crazyhyena.com/funny-kid-sleeping-on-a-dog

Alcohol Withdrawal

Reduced GABAA stimulation

Reduced NMDA inhibition

Leads to CNS excitation

Agitation

Delirium

Seizures

http://9st.org/bum-researcher/

Wernicke’s Encephalopathy

Low thiamine

Poor dietary intake

Administer IV dextrose

▼thiamine + D50 = Wernicke’s

Extreme B-vitamin depletion

Prophylaxis with thiamine

Korsakoff’s Syndrome

Low thiamine

Korsakoff’s psychosis

Poor longterm prognosis

IV thiamine, nutrition, hydration

Positive treatment can take years

https://goinggentleintothatgoodnight.com/tag/wernicke-korsakoff-syndrome/

Alcohol Withdrawal Timeline

6-8 hours

Anxiety, tremulousness, nausea

Professionals will seize

12-48 hours

Hallucinations

http://davidthebartender.blogspot.com/2015/08/drinking-hellfire-simple-guide-to.html

Delirium Tremens

Usually 48-96 hours

Fever

Hyperadrenergic

Agitation

Altered LOC

Care Plan

Rule out other etiologies

Quiet environment

Free from stimulation

May need restraints

Floor vs ICU

ICU Admission Criteria

Broadly accept

Significant comorbidities

High doses of meds

Electrolyte problems

Concern for GI bleeding

Withdrawal related

seizures …

https://www.uptodate.com/contents/image?imageKey=PULM%2F73377&topicKey=EM%2F323&search=alcohol%20withdrawal%20treatment&rank=1~143&source=see_link

CIWANV

Tremor

Sweats

Anxiety

Agitation

Auditory, tactile,

visual disturbances

Headache

Altered LOC

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

Galton’s Rule for Benzos in ICU

Only two options

Seizures

Alcohol withdrawal

Apply liberally

PO diazepam

IV lorazepam

https://www.uspharmacist.com/article/treatment-of-alcohol-withdrawal-syndrome

Phenobarbital

Work synergistically with benzos

Work OK independently

Dosing is 65 mg, 130 mg, 260 mg

Every 15-20 minutes

Makes anecdotal sense with GABAA

May require intubation

Dexmedetomidine Infusion

Textbook dose 0.1-1.5 mcg/kg/hr

Not a respiratory depressant

Hemodynamic instability(> 0.7)

Tolerance in days

Lacking any significant evidence

ICU admission?

Propofol

Mechanism of action

Strong respiratory depressant

Hemodynamic instability

May require intubation

Treatment vs anesthesia?

Ethanol Infusion

NOT recommended

Poor titratability

End organ damage

Metabolic instability

Review the Objectives

Review endocrine fundamentals

Highlight four ICU endocrine disorders

Discuss pathophysiology of alcohol

withdrawal

Review the treatment options

https://www.galveston.com/blog/573/stay-and-play-galveston-offers-gulf-fireworks-shows-every-sunday-this-summer/

Thanks for Inviting Me

SAD Treatment Plan

https://www.democratandchronicle.com/story/news/2017/03/15/latest-snowfall-totals-rochester-area/99202646/