Cost- And Time-Effective Strategies
- If myxedema coma is likely based on available history and physical examination, start thyroid replacement therapy. The clinical improvement in patients with myxedema coma is prolonged. Delaying treatment not only increases the risk of mortality but also increases the duration of the stay in the ICU.
- Avoid ordering complex endocrinologic tests from the ED. A TSH, FT4, T3, and random cortisol level ordered from the ED may assist consultants. However, these tests will need to be repeated in the course of the patient's hospitalization. Most tests of endocrine function are not time sensitive and can await consultation and recommendation by the endocrinologist.
- Aggressively control the peripheral effects of thyroid hormone in thyroid storm. Quickly titrating a continuous intravenous infusion of a b-blocking agent to control symptoms and signs of hyperthyroidism saves physician and nursing time and more rapidly improves patient symptomatology. The more quickly the patient is stabilized, the more quickly the patient can be transitioned to oral medication to avoid an ICU admission. A stepwise approach with repeated boluses or a trial of oral medication before intravenous medication delays the alleviation of patient symptoms, delays disposition of the patient, and requires multiple changes in therapy. Although the oral or repeated intravenous bolus is less expensive from a pure drug cost, the increased nursing time and prolonged ED stay make this a non–cost-effective strategy.
- Appropriately address the patient's volume status. Most patients with a thyroid crisis are hypovolemic. Beginning appropriate fluid resuscitation early in the patient evaluation expedites the patient's recovery. Reassess the patient often to gauge the response to fluid therapy.
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