Weathering the Storm: Thyroid Storm Precipitated by Radioiodine Contrast in Metastatic Thyroid Carcinoma

Thyroid storm is an extremely rare yet life-threatening medical emergency. It results from the decompensation of undiagnosed or undertreated hyperthyroidism in the presence of an acute stressor such as trauma to the thyroid, infections, acute iodine load, withdrawal from the antithyroid medication, or surgical procedures (including thyroid surgery). Clinical features of thyroid storm include hyperthermia, tachycardia, respiratory distress, gastrointestinal and hepatic symptoms, and central nervous system dysfunction. It is primarily a clinical diagnosis, further aided by abnormal thyroid function tests. Thyroid storm is associated with significant mortality and morbidity - the latter mostly related to complications from thyrotoxicosis or hyperthyroidism. Treatment with iodine (or iodide-ionized active form of iodine) supplements or with radioactive iodine, also known as radioiodine, such as in the treatment of thyroid cancer, is a common and mostly safe practice; however, iodine contrast in tomography imaging may precipitate a thyroid storm in sporadic cases. Here, we report a remarkable case of a 62-year-old African American female with a history of total thyroidectomy secondary to follicular thyroid cancer three years before the current presentation; she developed left lung pneumonia complicated by thyroid storm status post a computed tomography angiogram of the abdomen. She exhibited signs and symptoms of thyrotoxicosis a few days after receiving the iodinated contrast. The recommended daily iodide intake for adults with hyperthyroidism is about 150 mcg per day, while a computed tomography scan exposes patients to 14 to 35 million mcg of iodinated contrast at once, which could have triggered a storm. In this case, the patient was diagnosed with thyroid storm, which was presumed to be a consequence of the Jod-Basedow phenomenon secondary to metastatic thyroid carcinoma lesions discovered later. This clinical diagnosis was reinforced by laboratory results showing elevated serum free T4 and undetectable thyroid-stimulating hormone. She was treated with supportive measures, steroids, beta-blockers, and antithyroid medications with a positive outcome. This case demonstrated that, in the setting of recurrent metastatic thyroid cancer, clinicians should approach the use of intravenous iodine medium contrast in imaging with some level of caution when dealing with patients at risk of thyrotoxicosis or with underlying hyperthyroidism state at the brink of a storm.

Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

CONTEXT

There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU).

OBJECTIVE

To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria.

METHODS

In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to "do not resuscitate" (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs.

RESULTS

In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR-adjusted odds ratio (AOR) = 7.5; 95% CI 5.6-9.9) and hospice referrals-(AOR = 7.6; 95% CI 5.0-11.7). They had slightly lower 30-day readmissions-(AOR = 0.7; 95% CI 0.5-1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation-by Day 4 of admission-was associated with reductions in LOS (1.7 days [95% CI -3.1, -1.2]) and average direct variable costs (-$1815 [95% CI -$3322, -$803]) compared to those who received no PCC.

CONCLUSION

Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.

Suboptimal implementation of diagnostic algorithms and overuse of computed tomography-pulmonary angiography in patients with suspected pulmonary embolism

BACKGROUND:

Majority of our computed tomography-pulmonary angiography (CTPA) scans report negative findings. We hypothesized that suboptimal reliance on diagnostic algorithms contributes to apparent overuse of this test.

METHODS:

A retrospective review was performed on 2031 CTPA cases in a large hospital system. Investigators retrospectively calculated pretest probability (PTP). Use of CTPA was considered as inappropriate when it was ordered for patients with low PTP without checking D-dimer (DD) or following negative DD.

RESULTS:

Among the 2031 cases, pulmonary embolism (PE) was found in 7.4% (151 cases). About 1784 patients (88%) were considered “PE unlikely” based on Wells score. Out of those patients, 1084 cases (61%) did not have DD test prior to CTPA. In addition, 78 patients with negative DD underwent unnecessary CTPA; none of them had PE.

CONCLUSIONS:

The suboptimal implementation of PTP assessment tools can result in the overuse of CTPA, contributing to ineffective utilization of hospital resources, increased cost, and potential harm to patients.

Evaluation of screening criteria for palliative care consultation in the MICU: a multihospital analysis

BACKGROUND

There are currently no comprehensive studies in critical care settings that have set out to examine the association of palliative care screening criteria with multiple, adverse patient outcomes.

METHODS

A 7-item palliative care screen was developed from consensus reports. Medical intensive care unit (MICU) nurses at four hospitals screened patients upon admission during a 16-week period. Outcomes included percentage of patients screened and their percentage with consultations ordered. Patient screen scores were compared with mortality, hospice discharge and length of stay (LOS).

RESULTS

During the period, 1071 patients were admitted to MICUs, of which, 59.3% were screened; 35.3% of patients screened positive. Patients with positive screens (n=225) were more likely to have a consult ordered (33.6% vs 3.4%; p<0.001), and likelihood of consult increased with higher screen scores. Patients with positive screens had significantly longer hospital and MICU LOS (p<0.001), and had increased risk of inpatient mortality (p<0.001) and hospice discharge (p<0.001). Criteria of 'admission from a skilled nursing facility' and 'readmission to the ICU' were significant predictors of LOS; 'cancer,' 'post cardiac arrest,' and 'team perceived need' were predictors of the composite variable of mortality/hospice discharge. 'End-stage dementia' and 'intracranial bleed' were not predictive of adverse outcomes.

CONCLUSIONS

Decisions on the appropriateness for palliative care consultation in the MICU can be aided using a trigger screen. We recommend the use of this screen be considered in the MICU with the suggested revisions. Additional studies are needed to determine if the use of the trigger screen is associated with improved clinical outcomes.

Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients

STUDY OBJECTIVES

To determine the impact of early enteral feeding on the outcome of critically ill medical patients.

DESIGN

Retrospective analysis of a prospectively collected large multi-institutional ICU database.

PATIENTS

A total of 4,049 patients requiring mechanical ventilation for > 2 days.

MEASUREMENTS AND RESULTS

Patients were classified according to whether or not they received enteral feeding within 48 h of mechanical ventilation onset. The 2,537 patients (63%) who did receive enteral feeding were labeled as the "early feeding group," and the remaining 1,512 patients (37%) were labeled as the "late feeding group." The overall ICU and hospital mortality were lower in the early feeding group (18.1% vs 21.4%, p = 0.01; and 28.7% vs 33.5%, p = 0.001, respectively). The lower mortality rates in the early feeding group were most evident in the sickest group as defined by quartiles of severity of illness scores. Three separate models were done using each of the different scores (acute physiology and chronic health evaluation II, simplified acute physiology score II, and mortality prediction model at time 0). In all models, early enteral feeding was associated with an approximately 20% decrease in ICU mortality and a 25% decrease in hospital mortality. We also analyzed the data after controlling for confounding by matching for propensity score. In this analysis, early feeding was again associated with decreased ICU and hospital mortality. In all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP) developing.

CONCLUSION

Early feeding significantly reduces ICU and hospital mortality based mainly on improvements in the sickest patients, despite being associated with an increased risk of VAP developing. Routine administration of such therapy in medical patients receiving mechanical ventilation is suggested, especially in patients at high risk of death.