Diagnosis and management of thyroid disease and the critically ill patient.

OBJECTIVE To review current concepts in the diagnosis and management of thyroid disease in the critically ill patient. DATA SOURCES A review of articles reported on thyroid disease and the acutely ill patient. SUMMARY OF REVIEW Normal thyroid function depends on an integrated response between the pituitary and thyroid gland to provide an appropriate circulating T4 level which is converted to T3 by peripheral tissues. Thyroid hormone increases oxygen consumption and regulates lipid and carbohydrate metabolism and normal growth and maturation of tissues. In patients with a severe non-thyroidal illness, the thyroid stimulating hormone (TSH), free thyroxine (FT4) and free 3,5,3-triiodo-L-thyronine (FT3) levels decrease. Dopamine, dobutamine or corticosteroid therapy may also reduce TSH levels. The TSH and T4 levels often return to low normal levels, although with continued severe illness they may remain low. The clinically euthyroid state is maintained in the presence of a reduction in FT3 levels partly due to an increase in synthesis of tissues T3 receptors. During the recovery phase of the illness, there is often a transient elevation in the TSH level until the FT4 and FT3 levels are returned to normal. There are no clinical data that have shown a consistent reduction in mortality with thyroid hormone treatment in the critically ill patient. In general, in the absence of clinical signs of thyroid disease, abnormal thyroid function tests should not be treated in the critically ill patient and thyroid function studies should be repeated after the acute illness has resolved. Hypothyroid and hyperthyroid states may present with acute cardiorespiratory failure. Treatment that includes cardiorespiratory resuscitation and thyroid hormone replacement in hypothyroid states and beta adrenergic blockers in hyperthyroid states will often allow correction of the underlying disorder to be achieved successfully. CONCLUSIONS Abnormal thyroid function tests are commonly found in the critically ill patient and do not require treatment. However, hypothyroid and hyperthyroid states may present with acute cardiorespiratory failure and require careful and specific management strategies to resolve the thyroid disorder.