RESUMO
ABSTRACT Objective: Thyroid functions in the sick newborns may be altered in the first week of life. Transient hypothyroxinemia has been reported in these babies, which could be due to the immaturity of the hypothalamic-pituitary-thyroid axis or to acute illness. We conducted this study to estimate the incidence of hypothyroxinemia and determine its risk factors in sick term newborns. Materials and methods: We analyzed free T4 (FT4) and thyroid-stimulating hormone (TSH) levels in sick term neonates (≤7 days of life) admitted to the neonatal intensive care unit. FT4 and TSH levels were estimated in the first week of life in all the enrolled neonates (N = 98) and then repeated at 14-21 days of life in 46 babies. Risk analysis was conducted using univariate and multivariate logistic regression, and numerical data was compared using the Mann-Whitney U test and t-test. Results: Hypothyroxinemia was seen in 10 (10.2%) of the admitted term babies. Male gender, vaginal delivery, presence of hypoxic ischemic encephalopathy, and need for mechanical ventilation (>24 hours) were identified as risk factors. There was a significant negative linear correlation between FT4 level in the first week of life and duration of hospital stay. Conclusion: Hypothyroxinemia is common in sick term neonates.
RESUMO
Objective: Thyroid functions in the sick newborns may be altered in the first week of life. Transient hypothyroxinemia has been reported in these babies, which could be due to the immaturity of the hypothalamic-pituitary-thyroid axis or to acute illness. We conducted this study to estimate the incidence of hypothyroxinemia and determine its risk factors in sick term newborns. Materials and methods: We analyzed free T4 (FT4) and thyroid-stimulating hormone (TSH) levels in sick term neonates (≤7 days of life) admitted to the neonatal intensive care unit. FT4 and TSH levels were estimated in the first week of life in all the enrolled neonates (N = 98) and then repeated at 14-21 days of life in 46 babies. Risk analysis was conducted using univariate and multivariate logistic regression, and numerical data was compared using the Mann-Whitney U test and t-test. Results: Hypothyroxinemia was seen in 10 (10.2%) of the admitted term babies. Male gender, vaginal delivery, presence of hypoxic ischemic encephalopathy, and need for mechanical ventilation (>24 hours) were identified as risk factors. There was a significant negative linear correlation between FT4 level in the first week of life and duration of hospital stay. Conclusion: Hypothyroxinemia is common in sick term neonates.
Assuntos
Unidades de Terapia Intensiva Neonatal , Tiroxina , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Fatores de Risco , Doenças da Glândula Tireoide , TireotropinaRESUMO
RESUMO Objetivo: Avaliar a síndrome do doente eutireóideo como fator prognóstico em pacientes na unidade de terapia intensiva, detectar fatores que possam influenciar a mortalidade e desenvolver uma equação para calcular a probabilidade de morte. Métodos: Este foi um estudo de coorte longitudinal, observacional e não concorrente realizado na unidade de terapia intensiva da Fundação Santa Casa de Misericórdia do Pará. Realizou-se coleta de 20mL de sangue em 100 adultos sem endocrinopatia previamente documentada para a dosagem do hormônio estimulante da tireoide, da tetraiodotironina livre, da tri-iodotironina livre e da tri-iodotironina reversa. Resultados: A maioria dos pacientes era do sexo feminino, com idades entre 20 e 29 anos. A maioria dos pacientes que morreram era mais velha (idade mediana de 48 anos), e 97,5% deles possuíam a síndrome do doente eutireóideo. A síndrome do doente eutireóideo esteve relacionada à morte, às comorbidades, à idade e ao tempo de internação (mediana de 7,5 dias) na unidade de terapia intensiva. A baixa dosagem de hormônio estimulante da tireoide estava associada à morte. Os pacientes com dosagem da tri-iodotironina livre menor que 2,9pg/mL tinham maior probabilidade de morrer e, naqueles que morreram, a dosagem de tri-iodotironina reversa era maior que 0,2ng/mL. A tri-iodotironina livre apresentou maior sensibilidade e acurácia, e a tri-iodotironina reversa teve maior especificidade para prever a mortalidade. Com base nos resultados e pontos de corte, desenvolveu-se uma fórmula de regressão logística múltipla para calcular a probabilidade de morte. Conclusão: Sugere-se verificar oportunamente a dosagem da triiodotironina livre e reversa em pacientes graves e aplicar a equação proposta.
ABSTRACT Objective: To assess euthyroid sick syndrome as a prognostic factor in patients in the intensive care unit; to detect factors that may affect mortality; and to develop an equation to calculate death probability. Methods: This was a longitudinal, observational, nonconcurrent cohort study developed in the intensive care unit of Fundação Santa Casa de Misericórdia do Pará. One hundred adults with no prior documented endocrinopathy were submitted to a 20mL blood sample collection for the measurement of thyroid stimulating hormone, free tetraiodothyronine, free triiodothyronine and reverse triiodothyronine. Results: Most patients were female, aged 20 to 29 years. Most patients who died were older (median age of 48 years), and euthyroid sick syndrome was present in 97.5% of them. Euthyroid sick syndrome was related to death, comorbidities, age and length of stay in the intensive care unit (median of 7.5 days). There was an association between lower thyroid stimulating hormone and death. Patients with free triiodothyronine levels below 2.9pg/mL were more likely to die; reverse triiodothyronine rates were above 0.2ng/mL in those who died. Free triiodothyronine had greater sensitivity and accuracy, and reverse triiodothyronine had greater specificity to predict mortality. Based on the results and cutoff points, a multiple logistic regression formula was developed to calculate the probability of death. Conclusion: The main limitation of this study is the fact that it was conducted in a reference hospital for maternal and child care; therefore, there was a greater number of female patients and, consequently, a sampling bias existed. However, opportune measurement of free and reverse triiodothyronine levels in critical patients and application of the proposed equation are suggested.
RESUMO
Resumen: Introducción: La prevalencia del síndrome eutiroideo enfermo en pacientes con sepsis es aproximadamente de 60%; existe poca información sobre su correlación con falla multiorgánica. Objetivo: Estimar la prevalencia del síndrome eutiroideo enfermo (SEE) y correlacionar con la presencia de fallas orgánicas específicas y puntajes de gravedad y desenlaces clínicos. Métodos: Se incluyeron pacientes con diagnóstico de sepsis en una unidad de cuidados críticos durante el periodo comprendido de marzo de 2014 a febrero de 2016; se tomaron variables clínicas y estudios de laboratorio que incluían perfil tiroideo en todos los pacientes. Análisis estadístico: Estadística descriptiva con medidas de frecuencia, tendencia central y dispersión. Se realizaron análisis de supervivencia con modelos de regresión de Cox y curvas de Kaplan-Meier para mortalidad; razones de riesgo e intervalos de confianza de 95%. Un error alfa ajustado menor de 5% a dos colas fue considerado significativo. Se usó la paquetería estadística STATA SE versión 11.1. Resultados: Se incluyó un total de 90 pacientes, 51.1% de sexo femenino, con edad de 71 ± 14.15 años, IMC al ingreso a la UCI de 24.94 ± 5.07 kg/m2. La prevalencia global de SEE es de 61.1%. Los pacientes con SEE presentaron en mayor proporción falla hemodinámica, renal y hematológica, sin alcanzar significancia estadística. En la fases combinadas 2 y 3 de SEE, sí se observó mayor proporción de falla renal: 88 versus 63.3%, RR = 1.8 (IC 95% 1.1-2.6, p = 0.037), así como altas dosis de vasopresores (norepinefrina > 0.1 µg/kg/min) RR = 2.3 (IC 95% 1.063-5.18, p = 0.024) y menor supervivencia, con una mediana en días de 28 (RIQ 19-39) versus 26 (RIQ 13-36), p = 0.7; PCT igual o mayor a 6 en un 65.5 versus 40%, RR = 1.87 (IC 95% 1.1-3.1, p = 0.18), mayor puntaje de SOFA con mediana de 12 (RIQ 8-4) versus 9 (RIQ 7-13) puntos, p = 0.09. Además, peores desenlaces durante la estancia hospitalaria, evaluados por un índice compuesto que incluye mortalidad, necesidad de ventilación mecánica invasiva (VMI), SOFA ≥ 9 con un RR = 1.713 (IC 95% 1.036-2.83, p = 0.05). El análisis de curva ROC detectó el mejor punto de corte de SOFA como predictor de SEE ≥ 11 con sensibilidad 60.0, especificidad 62 LR + 1.6, LR - 0.63, AUC = 0.6. RR = 1.7 (IC 95% 1.024-3.05, p = 0.034). Conclusiones: Los pacientes con SEE presentan mayor elevación de marcadores de inflamación, requerimiento de vasopresores y soporte ventilatorio, compromiso multiorgánico y mortalidad.
Abstract: Introduction: The prevalence of euthyroid sick syndrome in patients with sepsis is approximately 60%; there is little information on its correlation with multiorgan failure. Objective: To estimate the prevalence of euthyroid sick syndrome (ESS) and correlate it with the presence of specific organ failures, severity scores and clinical outcomes. Methods: Patients with diagnosis of sepsis in a critical care unit during the period from March 2014 to February 2016; we registered the clinical variables and laboratory studies, including thyroid function, in all patients. Statistical analysis: Descriptive statistics with frequency measures of central tendency and dispersion. Mortality-survival analysis with Cox regression models and Kaplan-Meier were made, as well as risk ratios and confidence intervals of 95%. A two-tailed adjusted alpha error of less than 5% was considered significant. The statistical package STATA SE version 11.1 was used. Results: Ninety patients were included, 51.1% female, aged 71 ± 14.15 years; the BMI at admission to the ICU was 24.94 ± 5.07 kg/m2. The overall prevalence of ESS was 61.1%. ESS patients presented in greater proportion with hemodynamic, renal and hematologic failure, without reaching statistical significance. In the combined phases 2 and 3 of SEE, a higher proportion of renal failure was observed: 88 vs. 63.3 %, RR = 1.8 (95% CI 1.1-2.6, p = 0.037). High doses of vasopressors (norepinephrine > 0.1 µg/kg/min) RR = 2.3 (95% CI 1.063-5.18, p = 0.024). Lower survival with a median of 28 days (IQR 19-39) versus 26 (IQR 13-36), p = 0.7. PCT greater than or equal to 6 in 65.5 versus 40%, RR = 1.87 (95% CI 1.1-3.1, p = 0.18); higher SOFA score with a median of 12 (IQR 8-4) versus 9 (IQR 7-13) points, p = 0.09. In addition to worse outcomes during hospital stay evaluated by a composite index that included mortality, need for invasive mechanical ventilation (IMV), SOFA ≥ 9 with a RR = 1.713 (95% CI 1.036-2.83, p = 0.05). ROC curve analysis detected the best cut of SOFA as a predictor of ESS ≥11, sensitivity 60.0, specificity 62 LR + 1.6, LR-0.63, AUC = 0.6. RR = 1.7 (95% CI 1.024-3.05, p = 0.034). Conclusions: Patients with ESS have higher markers of inflammation, increased requirement for vasopressors and ventilatory support, as well as elevated multiorgan failure and mortality.
Resumo: Introdução: A prevalência da síndrome do doente eutireoidiano em pacientes com sepse é de aproximadamente 60%, além disso há pouca informação sobre sua correlação com a insuficiência de múltiplos órgãos. Objetivo: Estimar a prevalência da síndrome do doente eutireoidiano (ESS) e correlacionar com a presença de insuficiência orgânica específica, pontuações de gravidade e desenlaces clínicos. Foram incluídos pacientes diagnosticados com sepse em uma unidade de terapia intensiva durante o período de março de 2014 a fevereiro de 2016, se tomaram variáveis clínicas e estudos laboratoriais que incluiam perfil tireoidiano em todos os pacientes. Análise estatística: Estatística descritiva com medidas de frequência, tendência central e dispersão. Realizaram-se análises de sobrevivência com modelos de regressão de Cox e curvas de Kaplan-Meier para mortalidade. Taxas de risco e intervalos de confiança de 95%. O erro alfa ajustado menor a 5% bicaudal, serão considerados significativos. O programa estatístico STATA versão 11.1. Resultados: Incluiram-se um total de 90 pacientes, 51.1% do sexo feminino, com idades entre 71 ± 14.15 anos, IMC na admissão na UTI foi de 24.94 ± 5.07 kg/m2. A prevalência global de ESS foi de 61.1%. Os pacientes com ESS apresentaram maior proporção de alteração hemodinâmica, renal e hematológica sem alcançar significância estatística. Nas fases 2 e 3 combinadas de ESS se observou maior proporção de insuficiência renal 88 versus 63.3%, RR = 1.8 (IC 95%1.1-2.6, p = 0.037). Altas doses de vasopressores (norepinefrina > 0.1 µg/kg/min) RR = 2.3 (IC 95% 1.063-5.18, p = 0.024). Menor sobrevida com uma média em dias de 28 (IQR 19-39) vs 26 (RIQ 13-36), p = 0.7. PCT igual ou maior a 6 em um 65.5 vs 40%, RR = 1.87 (IC de 95% 1.1-3.1, p = 0.18) maior pontuação SOFA com uma média de 12 (RIQ 8-4) vs 9 (RIQ 7-13) pontos, p = 0.09. Ademais com piores desenlaces durante a estadia hospitalar avaliada por um índice de composto que inclui a mortalidade, a necessidade de VMI, SOFA ≥ 9 com um RR = 1.713 (IC 95% 1.036-2.83, p = 0.05). A análise da curva ROC detectou o melhor ponto de corte de SOFA como um preditor de ESS ≥ 11 sensibilidade 60.0, especificidade 62 LR + 1.6, LR-0.63, AUC = 0.6. RR = 1.7 (IC de 95% 1.024-3.05, p = 0.034). Conclusões: Os pacientes com ESS apresentam maior elevação dos marcadores inflamatórios, maior necessidade de vasopressores, suporte ventilatório, compromisso múltiplo de órgãos e mortalidade.
RESUMO
OBJECTIVE: The human heart expresses the type 2 deiodinase (D2) that activates thyroxine (T4) to triiodothyronine (T3). At the same time, the inactivating type 3 deiodinase (D3) has been found in a rat model of right ventricular hypertrophy. It is not known whether the human myocardium metabolizes thyroid hormone. This study examined myocardial thyroid hormone metabolism in patients with aortic valve stenosis (AS) undergoing aortic valve replacement and in patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting surgery. METHODS: Myocardial thyroid hormone metabolism was assessed by analyzing the difference in serum thyroid hormone levels between the aortic root (incoming blood) and the coronary sinus (outgoing blood) of patients undergoing cardiac surgery. A total of 23 patients with AS and 35 patients with CAD were included. Patients received a pre-surgical echocardiogram, and pre-, during and post-surgical thyroid hormone serum levels were collected in the myocardial and peripheral circulations. RESULTS: Patients with AS exhibited the expected left ventricle (LV) hypertrophy (i.e., 20-30% increase in LV posterior wall and interventricular septum thickness and â¼10% increase in AS in LV diastolic diameter). Immediately before cardiopulmonary bypass, blood flowing through the AS myocardium exhibited a 4.6% reduction in T3 and 6.9% increase in rT3 levels, decreasing the serum T3/rT3 ratio by 9.6%. T4 and thyrotropin serum levels remained similar between the aortic root and coronary sinus. In contrast, no myocardial thyroid hormone metabolism was observed in CAD patients. Notably, the AS myocardium lost the ability to inactivate thyroid hormone after cardiopulmonary bypass, possibly due to myocardial stunning. CONCLUSIONS: There is accelerated thyroid hormone inactivation in the AS myocardium, which is likely the result of D3 expression. No evidence to suggest thyroid hormone activation in the myocardium was obtained in the present study.