Further Inpatient Care
Further inpatient care is as follows:
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Admit patients with myxedema coma to ICU.
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Provide supportive ventilatory and hemodynamic management.
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Treat precipitating events (eg, infection).
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Continue rewarming as required.
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Confirm diagnosis with laboratory testing.
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Continue thyroid hormone replacement, and convert to oral therapy when tolerated.
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Clinical improvement should be apparent within 24-36 hours of initiating thyroid hormone replacement.
Complications
Potential complications are as follows:
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Treatment-induced congestive heart failure in patients with coronary artery disease
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Myxedema coma
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Increased susceptibility to infection
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Megacolon
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Organic psychosis with paranoia
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Adrenal crisis with vigorous treatment of hypothyroidism
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Hypersensitivity to opiates
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Pericardial effusion and cardiac tamponade [11]
Prognosis
The prognosis of hypothyroidism is good with early treatment. However, once the disease has progressed to myxedema coma, the mortality rate may exceed 20% in the treated population. Relapses occur if treatment is discontinued.
The mortality rate in myxedema coma has historically been as high as 80%. Some data suggest that aggressive management and early recognition have improved the mortality rate to 15-20%. However, a more recent observational study was unable to show significant differences in outcome based on replacement therapeutic methods, with a mortality rate remaining high at 40%. [12]
The aforementioned study by Ono et al reported that, as revealed through multivariable logistic regression, a higher inhospital mortality rate in myxedema coma was associated with older age and catecholamine use (with or without steroids). [4]
A study by Sato et al suggested that in patients with heart failure, those with subclinical hypothyroidism have a worse prognosis, finding a significant increase in the rates of cardiac events and all-cause mortality in heart failure patients in the study with subclinical hypothyroidism compared with those who were euthyroid. [13]
Patient Education
Patients should be educated about the following:
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Importance of medication compliance
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Need for lifelong treatment
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Watch for signs of infection
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Watch for signs of thyrotoxicity
For patient education resources, see the Endocrine System Center, as well as Thyroid Problems and Myxedema Coma.
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Pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette.
