Lecture_4_2013_12_04_19_18_15_370

-recurrent hyperthyroidism after course of antithyroid treatment. Precautions:

-patient must be euthyroid before operation.

Results of the surgery:

-normalization of thyroid gland function;

-postoperative recurrences (2-9 %);

-hypothyroidism (in about 3 % of patient the first years and in about 2 % with each succeeding year);

-vocal cord paralysis;

-hypoparathyroidism.

Iodine is used in preparing the patient for surgery. Surgical procedures are more difficult in patients who previously have undergone thyroidectomy or radioiodine therapy.

Treatment endocrine ophthalmopathy include:

-steroid therapy: prednisolone 20 – 40 mg daily;

-electrophoresis with glucocorticoids or KI;

-aloe, FIBS;

-dehydration therapy;

-cavinton, piracetam;

-lateral tarsorrhaphy: when there is corneal ulcer due to inability to close the lids;

-extra – ocular muscle surgery: to correct persistent diplopia.

Thyroid storm.

Thyroid storm is a lifethreatening emergency requiring prompt and specific treatment.

In is characterized by abrupt onset of more severe symptoms of thyrotoxicosis, with some exacerbated symptoms and signs atypical of uncomplicated Graves disease:

-fever;

-marked weakness and muscle wasting;

-extreme restlessness with wide emotional swings;

-confusion;

-psychosis or even coma;

-hepatomegaly with mild jaundice;

-the patient may present with cardiovascular collapse or shock.

Thyroid storm results from:- untreated or inadequately treated thyrotoxicosis It may be precipitated by:

-infection;

-trauma

-surgery;

-embolism;

-diabetic acidosis;

-fright;

-toxemia of pregnancy;

-labor;

-discontinuance of antithyroid medication;

-radiation thyroiditis.

Treatment of thyroid storm;

Iodine-30 drops Lugol’s solution/day orally in 30g 4 divided doses; or 1 to 2 gr. sodium iodide slowly by i/v drip.

Propylthiouracil (merkazolil) - 900 to 1200 mg/day orally or by gastric tube. Propranolol - 160mg/day orally in 4 divided doses; or 1mg slowly i/v g 4h under careful monitoring; a rate of administration should not exceed 1mg/min; a repeat 1mg dose may be given after 2 min i/v glucose solutions .

Correction of dehydration and electrolyte imbalance cooling blanket for hypertermia.

Digitalis if necessary.

Treatment of underlying disease such as infection.

Corticosteroids-100 to 300mg hydrocortisone/day i/v.

Iodine in pharmacological doses inhibits the release of T3 to T4 within hours and inhibits the organification of iodine, a transitory effect lasting from a few days to a week (”escape phenomenon”.)

Indications (it is used for)

-the emergency management of thyroid storm;

-thyrotoxic patients undergoing emergency surgery;

-preoperative preparation of thyrotoxic patients selected for subtotal thyroidectomy /since it also decreases the vascularity of the thyroid gland.

It is not used for routine treatment of hyperthyroidism. The usual dosage is 2 to 3 drops of satured potassium iodide solution orally tid or dig 1300 to 600 mg/day; or 0,5gr sodium iodide in 0,9% sodium chloride solution given i/v slowly g 12h.

Complication of iodine therapy include:

-inflammation of the salivary glands;

-conjunctivitis;

-skin rashes;

-a transient hyperthyroidism (iod-BASEDOW phenomenon) (it can be observed in patients with nontoxic goiters after administration of iodinecontrast agents).

Antithyroid drugs

Doses of PPU of 450-600 mg/day or greater 800 to 1200mg/day are generally reserved for the patient with thyroid storm, because such doses block the peripheral conversation of T4 to T3.

β-adrenergic blocking drugs. Propranolol rapidly decreases heart rate, usually within 2 to 3 h when given orally and within minutes when given i/v.

References.

1.The Merck Manual of Diagnosis and Therapy (fourteenth Edition)/ Robert Berkow and others. – published by Merck Sharp & Donhme Research Laboratories, 1982. – P.997 – 1001.

2.Manual of Endocrinology and Metabolism (Second Edition)/ Norman Lavin. – Little, Brown and Company.- Boston-New York-Toronto-London, 1994. - P. 371 - 380.

3.Endocrinology (A Logical Approach for Clinicians (Second Edition)). William Jubiz.-New York: WC Graw-Hill Book, 1985. - P. 68 – 91.

Prepared by Martynyuk L.P.

Adopted at the Chair Sitting 7.11.02.

Revised