Title: COMMON INPATIENT ENDOCRINE CONSULTS
1COMMON INPATIENT ENDOCRINE CONSULTS
2Thyroid disorders
- Effects of nonthyroidal illness (NTI, euthyroid
sick) - Effects of drugs
- Hyperthyroidism
- Hypothyroidism
- Post-thyroidectomy consults
3Nonthyroidal illness (NTI)
- Deiodinase inhibition gt decreased T3
- TSH suppression
- T4 FT4 suppression
4Nonthyroidal illness
5NTI diagnostic problems
- Low TSH NTI vs hyperthyroidism
- Clinical signs, including atrial fibrillation
- FT4
- Low-normal probably NTI, especially if TSH gt0.1
mU/ml - High hyperthyroidism
6NTI diagnostic problems
- Low FT4 NTI vs hypothyroidism
- Clinical signs, eg bradycardia, hypoventilation,
hypothermia - TSH
- gt20 mU/ml primary hypothyroidism
- 5-20 primary hypothyroidism vs NTI
- Repeat in 1-2 weeks or treat empirically and
reassess as outpatient - lt5 NTI vs secondary hypothyroidism
- History or evidence of pituitary disease?
7Thyroid function drug effects
- Iodine (amiodarone, X-ray contrast)
- Hyperthyoidism
- Hypothyroidism
- Amiodarone inhibits deiodinase
- Increased FT4, slightly increased TSH
- Lithium inhibits T4 release -gt hypothyroidism
- Heparin increases free T4 (in vitro)
- Furosemide displaces T4 -gt increased FT4
8Hyperthyroidism indications for emergency
management
- Acute coronary syndrome
- Heart failure
- Thyroid storm
- fever
- agitation or stupor
- severe concomitant illness
9Hyperthyroidismemergency management
- Confirm hyperthyroidism (free T4, TSH)
- Propylthiouracil (PTU) 200-300 mg PO Q 6 hr
- Iodine (SSKI) 2 gtt (80 mg) PO Q 12 hr
- Beta- adrenergic antagonist if not in CHF
- propranolol 40 mg Q 6 hr
- adjust dose to HR lt100/min
10Hyperthyroidismemergency management
- Intensive therapy of concomitant disease
- Follow free T4 Q 4-6 days
- When free T4 normal, schedule RAI therapy
- stop iodine 2-4 weeks before
- stop PTU 3-5 days before
11Hypothyroidism emergent therapy
- Indications
- Hypoventilation
- Bradycardia
- Hypotension
- Confirm diagnosis FT4, TSH
- T4 50-100 mg IV Q 6 hr x 24 hr, then
- T4 75-100 mg IV Q 24 hr
12Post-thyroidectomy consults
- Monitor for hypocalcemia Q 12-24 hr
- Benign disease
- Subtotal thyroidectomy start T4 TSH in 6-8
weeks - Lobectomy T4 or no therapy TSH in 6-8 weeks
- Thyroid carcinoma
- High risk for recurrence
- hold T4
- contact Radiation Oncology
- RAI ablation or whole body RAI scan in 2 weeks,
then - Start T4
13Calcium disorders
- Hypercalcemia
- Hypocalcemia
- Post-op parathyroidectomy consults
14Severe hypercalcemia signs
- Renal
- polyuria, dehydration
- renal failure
- Gastrointestinal
- nausea, vomiting, constipation
- abdominal pain
- Neurologic
- fatigue, confusion
- coma
15Severe hypercalcemia causes
- Malignancy
- Breast carcinoma
- Squamous lung carcinoma, head neck carcinoma
- Myeloma
- Renal carcinoma
- Primary hyperparathyroidism
- Miscellaneous
- vitamin D intoxication
- milk-alkali syndrome (calcium carbonate)
16Severe hypercalcemia evaluation
- Evidence of cancer
- Breast mass h/o breast cancer
- h/o smoking, cough, hemoptysis, mass on CXR
- Weight loss, anemia, etc
- Evidence of primary hyperparathyroidism
- Hypercalcemia for gt6 months
- h/o renal stones
- Plasma PTH, 25-OH vitamin D
- (SPEP, PTH-rP, 1,25-OH D, bone scan)
17Severe hypercalcemia indications for emergency
Rx
- Severe symptoms of hypercalcemia
- Plasma Ca gt12 mg/dl
18Severe hypercalcemia therapy
- Restore ECF volume
- Normal saline rapidly
- Positive fluid balance gt2 liters in first 24 hr
- Saline diuresis
- Normal saline 100-200 ml/hr
- Replace potassium
- Zoledronic acid 4 mg IV over 15 min
- if plasma Ca gt14 mg/dl or gt12 mg/dl after
rehydration - Monitor plasma calcium QD
- Myeloma or vitamin D toxicity
- prednisone 30 mg BID
19Hypocalcemia clinical signs
- Paresthesiae
- Tetany
- Trousseaus, Chvosteks signs
- Seizures
- Chronic cataracts, basal ganglia Ca
20Hypocalcemia causes
- Hypoparathyroidism
- Surgical
- Autoimmune
- Magnesium deficiency
- PTH resistance
- Vitamin D deficiency
- Vitamin D resistance
- Other renal failure, pancreatitis, tumor lysis
21Hypocalcemia evaluation
- Confirm low ionized calcium
- History
- Neck surgery
- Other autoimmune endocrine disorders
- Causes of Mg deficiency
- GI disorders (malabsorption)
- Family history
22Hypocalcemia evaluation
- Physical exam
- Signs of tetany
- Signs of pseudohypoparathyroidism
- Lab
- PTH, total ionized calcium
- Creatinine, Mg, P
- (25-OH vitamin D)
23Hypoparathyroidism therapy
- IV calcium infusion
- 2 gm Ca gluconate (20 ml) IV over 10 min
- 6 gm Ca gluconate/500 cc D5W over 6 hr
- Follow plasma Ca P Q 4-6 hr adjust rate
- Oral calcium 1-2 gm BID - TID
- Oral calcitriol 0.25-2 mcg/day
24Post-op parathyroidectomy
- Monitor for hypocalcemia
- Limited surgery plasma calcium at discharge
followup - 4-gland exploration plasma calcium Q 6-12 hr
- If hypocalcemia develops, consider
- Hypoparathyroidism
- Hungry bone syndrome (elevated alkaline
phosphatase) - Vitamin D deficiency
- Treat if
- Symptomatic or Trousseasus positive
- Plasma calcium lt8 mg/dl
25Adrenal disorders
- Adrenal failure
- Post-op adrenalectomy consults
- Steroid coverage for illness, surgery
- Severe hypertension, R/O adrenal cause
26Adrenal failure signs
- Weakness fatigue
- Anorexia weight loss
- Nausea vomiting
- Lethargy, stupor
- Hyponatremia
- Hypotension
- Shock death
- Hyperkalemia
- Hyperpigmentation
Only in primary adrenal failure
27Adrenal failure causes
- Primary (cortisol aldosterone deficient)
- AUTOIMMUNE
- tuberculosis, fungal infections
- Hemorrhage, sepsis, etc
- Secondary (ACTH cortisol deficient)
- GLUCOCORTICOID THERAPY
- hypothalamic or pituitary lesions
28Adrenal failure evaluation
- Dexamethasone 10 mg IV if hypotensive
- Cortrosyn stimulation test
- Cortrosyn 250 mcg IV
- Plasma cortisol _at_ 30 min
- Normal gt20 mcg/dl
- Not sensitive for new onset secondary adrenal
failure - Eg, after pituitary surgery, pituitary apoplexy
- Treat empirically with prednisone for 4 weeks
- Hold prednisone AM of test
29Adrenal failureemergency therapy
- Indications
- Hypotension
- Stupor
- Severe hyperkalemia or hyponatremia
- Hydrocortisone 100 mg IV Q 8 hr
- or dexamethasone 4 mg Q 12 hr
- D5/normal saline
30Post-op adrenalectomy
- Cushings syndrome due to adrenal adenoma
- Perioperative hydrocortisone 50 mg IV Q 8 hr
- Rapid taper to prednisone 10 mg QAM 5 mg QPM
- Incidentaloma
- ? Subclinical Cushings syndrome
- Dexamethasone Cortrosyn stimulation test
- Aldosteronoma
- Stop spironolactone monitor BP, plasma K
- Pheochromocytoma
- Stop phenoxybenzamine monitor BP
- IV NS for hypotension
31Steroid coverage
- Indications
- Known adrenal failure
- Chronic steroid treatment
- Recent (1 year) chronic steroid treatment
- For severe illness, major surgery
- Hydrocortisone 50 mg IV Q 8 hr
- For moderate illness, minor surgery
- Hydrocortisone 25 mg IV Q 8 hr
- Post-op, taper to chronic replacement over 2-3
days
32Severe hypertension
- Pheochromocytoma
- Primary hyperaldosteronism
- Cushings syndrome
- Evaluation
- Plasma K if low, plasma aldosterone/PRA
- Plasma catecholamines metanephrines
- Overnight dexamethasone suppression if clinical
signs of Cushings syndrome (may be falsely
positive)
33Pituitary disorders
- Sella turcica mass
- Post-op pituitary surgery
34Sellar or suprasellar mass
- Pituitary hormone excess
- Prolactin
- GH (acromegaly)
- ACTH (Cushings disease)
- Pituitary hormone deficiency
- Hypothyroidism, adrenal failure, hypogonadism
- Diabetes insipidus
- Mass effects
- Headache
- Visual field loss
- Pituitary apoplexy
- Incidental finding (10 have microadenomas)
35Pituitary disease evaluation
- Signs of hormone excess or deficiency
- Informal visual fields
- Labs
- Prolactin
- Free T4
- Cortrosyn stimulation test
- Women menstrual history men plasma
testosterone - MRI pituitary protocol
- Formal visual fields if mass contacts chiasm
36Post-op pituitary surgery
- Perioperative steroid coverage
- Treat pre-operative hypothyroidism, hypogonadism
- Taper steroids discharge on prednisone 5 mg QAM
- If polyuria develops
- monitor urine output plasma Na Q 6-12 hr
- Limit fluids to 75-100 cc/hr
- If hypernatremic DDAVP 1-2 mg SC or IV x 1, then
follow urine output
37Post-op pituitary surgery
- Outpatient followup 4 weeks after discharge
- Free T4
- Cortrosyn stimulation test
- Plasma testosterone in men
- Acromegaly IGF-1
- Cushings disease consider dexamethasone
suppression test
38Unexpected hypoglycemia
- Severe illness
- Hepatic failure
- Renal failure
- Sepsis
- Sulfonylurea or insulin administration
- Insulinoma
39Unexpected hypoglycemia
- BEFORE TREATMENT WITH GLUCOSE
- BMP lab glucose to confirm Accuchek
- Plasma insulin
- Plasma C-peptide
- Plasma proinsulin
- ANY TIME CLOSE TO HYPOGLYCEMIA
- Plasma sulfonylurea assay
- Call chemistry lab medicine resident to confirm
samples received
40Helpful phone numbers names
- Chemistry lab medicine resident 424-1153
- Nuclear medicine (docs) 362-2802
- Barnes Drug Information 454-8399
- Endocrine surgeons
- Jeffrey Moley
- Michael Brunt
- Bruce Hall
- Will Gillanders