syndrome of inappropriate antidiuretic hormone

SIADH is a relatively common complication of surgery or critical

illness.
In myxedema coma,
a CT scan, MRI,
or skull X-ray may
disclose an underlying
cause, such as
pituitary or hypothalamic
lesions
What causes it
The most common cause of SIADH is oat-cell lung cancer, which
secretes ADH or a vasopressor-like substance that the body
responds to as if ADH were secreted.
Many other possibilities
Other causes include:
neoplastic diseases (pancreatic, brain, and prostatic tumors;
Hodgkins disease; and thymoma)
brain abscess
stroke
Guillain-Barr syndrome
pulmonary disorders
adverse effects of medications (chlorpropamide, tolbutamide,
vincristine, cyclophosphamide, haloperidol,
carbamazepine, clofibrate, morphine, and thiazides)
adrenal insufficiency
anterior pituitary insufficiency.
how it happens
In SIADH, ADH is secreted excessively and the body
responds by retaining water. Fluid shifts within compartments
cause decreased serum osmolality.
What to look for
Most commonly, a patient with SIADH complains of anorexia,
nausea, and vomiting. Despite these symptoms, the patient may
report weight gain. Assessment findings may also include:
thirst
neurologic changessuch as lethargy, headache, and emotional
and behavioral changesand sluggish deep tendon reflexes
tachycardia associated with increased fluid volume
hyponatremia.
What tests tell you
Diagnosis of SIADH involves both blood and urine testing:
Serum osmolality is decreased (less than 280 mOsm/kg).
Urine sodium is increased (greater than 20 mEq/day).
Serum sodium level is decreased.
ADH level is elevated.
how its treated
Treatment is based on the underlying cause and the patients
symptoms.
In SIADH, excessive
ADH is secreted and
the body responds
by retaining water.
It isnt what you
want for bathing suit
First thing first
Treatment begins with restricting fluid intake to 500 to
1,000 mL/day. Other measures may include administration of
200 to 300 mL of 3% to 5% sodium chloride solution for patients
with severe hyponatremia. A loop diuretic may also be ordered to
reduce the risk for heart failure after administration of hypertonic
sodium chloride solution.
What to do
Assess the patients neurologic, cardiac, and respiratory status.
Implement seizure and safety precautions if the patients serum
sodium levels are dangerously low. Monitor serum electrolyte levels.
Monitor the patients vital signs, oxygen saturation, and cardiac
rhythm for potential arrhythmias.
Administer medications and I.V. fluids as ordered. If hypertonic
sodium chloride is ordered, monitor for fluid overload and administer
diuretics as ordered.
Monitor the patients intake and output and daily weight.
Enforce fluid restrictions and explain to the patient and his family
why this is necessary.


thyroid storm
Thyroid storm, also called thyrotoxic crisis, is a life-threatening
emergency in a patient with hyperthyroidism. Thyroid storm may
be the initial symptom in a patient with hyperthyroidism that hasnt
been diagnosed.
What causes it
The onset of thyroid storm is almost always abrupt and evoked by
a stressful event, such as trauma, surgery, or infection.
Not-so-common causes
Other, less common causes include:
metastatic carcinoma of the thyroid
pituitary tumor secreting TSH
diabetic ketoacidosis
poor compliance with antithyroid therapy.
how it happens
Thyroid storm develops when theres a surge of thyroid hormones.
Hyperthyroidism can result from genetic and immunologic
factors.
Help me, please!
The patient may need
a loop diuretic to
reduce the risk for
heart failure.
Thyroid storm
is a life-threatening
emergency
in a patient with
Graves is grave
Graves diseasethe most common form of hyperthyroidismis
an autoimmune process in which the body makes an antibody
similar to TSH and the thyroid responds to it. Overproduction of
T3 and T4 increases adrenergic activity and severe hypermetabolism
results. This can rapidly lead to cardiac, sympathetic nervous
system, and GI collapse.
What to look for
A patient in thyroid storm initially shows marked tachycardia,
vomiting, and stupor. Other findings may include:
irritability and restlessness
vision disturbances such as diplopia
tremor
tachycardia and cardiac arrhythmia
weakness
heat intolerance
angina
shortness of breath
cough
swollen extremities
exophthalamos.
Raise the flag
On palpation, an enlarged thyroid may be felt. Any change in
LOC and increasing temperature in a patient with hyperthyroidism
should raise red flags. Fever, typically above 100.4F (38C),
begins insidiously and rises rapidly to a lethal level. Without treatment,
the patient may experience vascular collapse, hypotension,
coma, and death.
What tests tell you
These diagnostic test findings may indicate impending thyroid
storm:
Serum T3 and T4 levels are elevated.
TSH level is decreased.
Radioisotope scanning shows increased uptake.
CT scan or MRI may disclose an underlying cause such as pituitary
lesion.
A 12-lead ECG may show atrial fibrillation and supraventricular
tachycardia.
how its treated
Immediate treatment for a patient with thyroid storm is necessary
to prevent death and includes:
beta-adrenergic blockers to block adrenergic effects
propylthiouracil and methimazole to block thyroid hormone
synthesis
possible corticosteroid administration to block conversion of T3
and T4
avoidance of aspirin because salicylates block binding of T3 and
T4
cooling measures such as use of a hyperthermia-hypothermia
blanket.
What to do
Assess the patients LOC and cardiopulmonary status.
Monitor the patients vital signs and core body temperature
and institute cooling measures such as use of
a hyperthermia-hypothermia blanket.
Monitor ECG readings. Increased adrenergic activity
may produce arrhythmias.
Monitor the patient for signs of heart failure.
Monitor I.V. fluids and fluid and electrolyte balance.
Monitor the patient for high blood glucose levels.
Excessive thyroid activity can lead to glycogenolysis.
Provide a quiet environment.