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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 2  |  Page : 92-96

Thyroid hormones; plasma level in critical ill patients need prolonged mechanical ventilation


Department of Anesthesia, Faculty of Medicine, Al-Azhar University, Nasr City, Cairo, Egypt

Date of Submission23-Apr-2017
Date of Acceptance30-Aug-2017
Date of Web Publication21-Nov-2017

Correspondence Address:
Abdelazim A.T Hegazy
Assistant Professor of Anesthesia, Faculty of Medicine, AL-Azhar University, Nasr City, Cairo, 00202
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_22_17

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  Abstract 


Background Thyroid function usually downregulates during stressful conditions. Thyroid dysfunction is associated with the mortality of patients under mechanical ventilation (MV) in the ICU.
Aim The aim of this study was to measure the thyroid hormonal level in the plasma of critical ill patients on prolonged MV.
Patients and methods Fifty patients were participated and completed the present study. The thyroid hormones: thyroid stimulating hormone, tri-thyroxine (T3), tetra-thyroxine (T4), reverse tri-thyroxine (rT3), were collected from the plasma: and tested as follows. The first sample was collected just before initiation of MV; second sample 24 h after initiation of MV; third sample: 24 h after successful weaning from MV. Venous blood samples were collected from each patient in nonheparinized blood collecting tubes, and the samples were allowed to clot at room temperature. All samples were centrifuged within 2 h after withdrawal and stored at 20°C until assayed.
Results The investigators have noticed that the patients, who were weaned off from MV in a period of less than 16 days, have good prognosis and who have been for a period of more than 16 days were classified as bad prognosis patients. Plasma levels of thyroid stimulating hormone, T4 and T3 in both good prognostic patients and bad prognostic patients were determined; there are clinical (died in bad group or survived in good prognosis group) and little mathematical difference between both groups, but of no significance statistically. The plasma level of rT3 in both good prognostic patients and bad prognostic patients has a high level in the second sample, and there are clinical and little mathematical difference between both groups but no significance statistically.
Conclusion The study of the level of thyroid hormones can give an idea about the progress of management of critically ill patients who undergo prolonged MV.

Keywords: critical illness, prolonged mechanical ventilation, thyroid hormones activities


How to cite this article:
Hegazy AA, Mostafa EA, Ahmed Hussein AN. Thyroid hormones; plasma level in critical ill patients need prolonged mechanical ventilation. Al-Azhar Assiut Med J 2017;15:92-6

How to cite this URL:
Hegazy AA, Mostafa EA, Ahmed Hussein AN. Thyroid hormones; plasma level in critical ill patients need prolonged mechanical ventilation. Al-Azhar Assiut Med J [serial online] 2017 [cited 2018 Jun 20];15:92-6. Available from: http://www.azmj.eg.net/text.asp?2017/15/2/92/218850




  Introduction Top


Critical illness is a lifethreatening process that, in the absence of medical intervention, is expected to result in mortality. It may be the product of one or more of the underlying pathophysiological processes; however, the result is a multisystem progression that ultimately involves respiratory, cardiovascular, and neurological compromise [1]. Reactions to stress include an activated hypothalamic–pituitary–adrenocortical axis associated with enhanced secretion of a number hormones such as glucocorticoid, prolactin, a low activity state of thyroid axis, etc. [2]. Thyroid function usually downregulates during stressful conditions. Thyroid dysfunction is associated with the mortality of patients under mechanical ventilation (MV) in the ICU; these alterations in the thyroid hormone is referred to as the ‘euthyroid sick syndrome’ or the nonthyroid illness syndrome [3]. Most patients require a short period of respiratory support, but a minority of patents require prolonged mechanical ventilation (PMV). Owing to a lack of definition of PMV, the accepted definition is a period of MV support of greater than 96 h for at last 6 h/day. It is estimated that between 4 and 13% of mechanically ventilated critically ill patients require PMV [4].


  Aim Top


The aim of the study was to measure the thyroid hormonal level in the plasma of critically ill patients on PMV.


  Patients and methods Top


This prospective study was carried out on patients known to have a critical illness that endangers their lives and in need of PMV and were been admitted to ICU in the period from January 2014 to September 2015. Approval was obtained from the Research/Ethics Committee of the Faculty of Medicine, Al-Azhar University and written informed consents had been taken from the relatives of all patients. Excluded patient include; anyone who could not have continued the study, having any thyroidal disorders, postsurgical or postoperative, post-trauma patient, patient with metabolic disorders of known malignancy, hepatic, renal, pregnant, or lactating woman.

Eighty-seven critically ill patients were admitted to the ICU. Twenty-two patients of the admitted patients refused to participate in the study, whereas 15 patients did not continue the study for different reasons: ventilator-dependent patients, severe cardiac or respiratory insufficiency, sudden death, etc. The rest of the patients (50 patients) completed the study. Plane of the study: full patient data were collected; ventilatory parameters were settled; and adjusted with frequent arterial blood gases, a proper analgesia and sedation regime was used and a monitoring system was applied. The thyroid hormones such as the thyroid stimulating hormone (TSH), tri-thyroxine (T3), tetra-thyroxine (T4), and reverse tri-thyroxine (rT3) were collected from the plasma and tested as follows:
  1. First sample: just before initiation of MV.
  2. Second sample: 24 h after initiation of MV.
  3. Third sample: 24 h after successful weaning from MV.


Venous blood samples were collected from each patient in nonheparinized blood collecting tubes and the samples were allowed to clot at room temperature. All samples were centrifuged within 2 h after withdrawal and stored at 20°C until assayed ([Table 1]).
Table 1 Laboratory references and technique

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TSH, T3, T4, rT3 were measured in plasma specimen using a commercial kit according to manufacturer’s sensitized protocol (coat-A-court IRMA; Siemens Medical Solutions Diagnostic, 5700W 96th St Los Angeles CA 90045-5544, USA), using Roche Elecsys 2010 chemistry analyzer and Cobas Integra 400 plus system (Roche Diagnostics 9115 Hague Road PO Box 50457, Indianapolis, IN 46250-0457, USA) analyzer with system Cobas Integra 400 plus ([Figure 1]; http://www.ecareagora.com/images/ProductImage/Roche%20Diagnostics/Roche%20Elecsys%20Systems.jpgf).
Figure 1 Roche Elecsys 2010 chemistry analyzer.

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Statistical analysis

Data were coded and entered using the statistical package SPSS version 21 (SPSS Inc., Chicago, Illinois, USA). Data were summarized using mean, SD, and frequencies (number of cases) and relative frequencies (percentages) for categorical variables. Comparisons between groups were done using analysis of variance followed by post-hoc test if there was significance in normally distributed quantitative variables. χ2-Test was used to compare frequency and percentage. P value less than 0.5 was considered significant.


  Results Top


A total of 50 patents completed the study till successfully weaned off either with bad prognosis (15 patients) or good prognosis (35 patients). The investigators have noticed that the patients, who were weaned off from MV in a period (its mathematic mean) of less than 16 days have good prognosis and those with mean more than 16 days have bad prognosis. Patient’s demographic data show a mean age of 48.4 years, 92% of them being men and 8% being women. Patients with good prognosis represented 70% of all shared patients and length of patient’s stay in the ICU was shorter (14.6 days) in good prognosis patients than in patients with bad prognosis (19.8 days) as in [Table 2].
Table 2 Patient characters and demographic data

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Regarding the plasma level of TSH in good prognostic patients and bad prognostic patients, there was clinical (died in the bad group or survive in good prognosis group) and little mathematical difference between both groups but none was statistically significant ([Table 3]).
Table 3 Thyroid stimulating hormone hormonal profile for bad and good prognostic patients

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Regarding the plasma level of T4 in both good prognostic patients and bad prognostic patients, there was clinical (died in bad group or survive in good prognosis group) and little mathematical difference between both groups but none were statistically significant ([Table 4]).
Table 4 Tetra-thyroxine hormonal profile for bad and good prognostic patients

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Regarding the plasma level of T3 in both good prognostic patients and bad prognostic patients, there was clinical (died in bad group or survive in good prognosis group) and little mathematical difference between both groups but none was statistically significant ([Table 5]).
Table 5 Tri-thyroxine hormonal profile for bad and good prognostic patients

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Regarding the plasma level of rT3 both good prognostic patients and bad prognostic patients had high level in the second sample, and there are clinical (died in bad group or survive in good prognosis group) and little mathematical difference between both groups but none were statistically significant ([Table 6]).
Table 6 Reverse tri-thyroxine hormonal profile for bad and good prognostic patients

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  Discussion Top


One adverse response to MV is complex neuroendocrine response to maintain hemodynamic homeostasis [5]. The endocrine alterations in the early period of MV appear to direct to reduce energy and substrate expenditure, thereby pushing back costly anabolism and forcing the substrates to release vital tissues to improve survival [6]. The reduction in hormone concentrations generally reflect diminished secretion, except for thyroid hormones, where altered metabolic pathways and enhanced metabolic clearance play a major role [7].

The present study shows that the investigators have noticed that the patients, who were weaned off from MV in a period of less than 16 days have good prognosis and who have a period of more than 16 days were classified as bad prognosis patients. Patient’s demographic data show a mean age of 48.4 years, with 92% being men and 8% being women. Patients with good prognosis represented 70% of all shared patients and the length of patient’s stay in the ICU was shorter in good prognosis patients than in patients with bad prognosis.

The present study demonstrated a plasma level of TSH, T4, and T3 in both good prognostic patients and bad prognostic patients. There are clinical (died in bad group or survived in good prognosis group) and little mathematical difference between both groups but there was no statistical significant. However, the plasma level of rT3 in both good prognostic patients and bad prognostic patients has a high level in the second sample, and there are clinical and little mathematical difference between both groups but none were statistically significant.

In a previous study, Clohesy et al. [8], who were assessing the relation between thyroid function test level with mortality and morbidity in critical illness supported by MV, the study shows no morbidity in patients, with a mean stay of 12 days but shows morbidity with patients whom have a mean stay of 21 days. T3 and rT3 were the most rapid and consistent change in serum concentration of thyroid hormones; there was a drop in T3 and an increase in rT3 level in patients of both groups, which were measured after 24 h of the onset of MV but TSH and T4 were within normal levels. Anna et al. [9], who state that the severity of critical illness especially (sepsis and septic shock) with MV is associated with various patterns of thyroid hormone abnormalities. The study concluded that decreased thyroid function at baseline might be associated with a worse outcome of patients with sepsis or septic shock. Tanaka et al. [10], state that thyroid hormones (TSH, T4, T3, and rT3) evaluated using sequential serum samples collected at 24 h interval, starting from intubation time as basal reference, showed that T3 or T4 was lower in the group of patients who had unfavorable (bad) outcome with high rT3 and TSH in the same group compared with the favorable (good) outcome. As mentioned above, the previous studies were in line with the present study.


  Conclusion Top


The study of thyroid hormones level can give an idea about the progress of management of critically ill patients who undergo PMV.

The present study has some limitations. The study was conducted on critically ill patients, who need PMV, so its results cannot be extrapolated to patients who do not need PMV.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Macintyre NR. Respiratory function during pressure support ventilation. Chest J 2010; 89:677–683.  Back to cited text no. 1
    
2.
Wang F, Pan W, Pan S, Wang S, Ge Q, Ge J. Usefulness of N-terminal probrain natriuretic peptide and C-reactive protein to predict ICU mortality in unselected medical ICU patients: a prospective, observational study. Crit care 2012; 15:R42–R48.  Back to cited text no. 2
    
3.
Russell DH. New aspects of prolactin and immunity: a lymphocyte-derived prolactin-like product and nuclear protein kinase C activation. Trends Pharmacol Sci 2014; 35:510–519.  Back to cited text no. 3
    
4.
Helmerich DL, Parfitt DB, Lu XY, Akil H, Watson SJ. Relation between the hypothalamic-pituitary-thyroid (HPT) axis and the hypothalamic-pituitary-adrenal (HPA) axis during repeated stress. Neuroendocrinology 2014; 81:183–192.  Back to cited text no. 4
    
5.
Shinozaki M, Muteki T, Kaku N, Tsuda H. Hemodynamic relationship between renal venous pressure and blood flow regulation during positive end expiratory pressure. Crit Care Med 2014; 16:14–21.  Back to cited text no. 5
    
6.
Takala J, Ruokonen E, Webster NR. Increased mortality associated with growth hormone treatment in critically ill adult. N Engl J Med 2012; 367:2461–2468.  Back to cited text no. 6
    
7.
Andrivet P, Adnot S, Sanker S, Chabrier P, Macquin-Mavier I, Braquet P. Hormonal interactions and renal function during mechanical ventilation and ANF infusion in humans. J Appl Physiol 2015; 71:287–292.  Back to cited text no. 7
    
8.
Clohesy J, Petty G, Paschall F. Using drug chronotherapy during mechanical ventilation. Crit Care Nurs Q 2006; 9:52–58.  Back to cited text no. 8
    
9.
Anna G, Angelousi L, Drosos E, Anastasios M, Matthew E. Association between thyroid function tests at baseline and the outcome of patients with sepsis or septic shock: a systematic review. Eur J Endocrinaol 2011; 164:147–155.  Back to cited text no. 9
    
10.
Tanaka S, Sagawa S, Miki K, Claybaugh J, Shiraki K. Changes in thyroid gland activity and renal function during positive-pressure breathing in humans. Am J physiol 2014; 266:R1220–R1228.  Back to cited text no. 10
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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