Perioperative management of a patient with myxedema coma and septicemic shock
A 61-year-old lady, known case of hypothyroidism for 20 years, was admitted in surgical emergency with complaints of abdominal pain and distension for 3 days. She had no recent thyroid function test (TFT) reports.\nOn examination, she was found to be drowsy but arousable. Her pulse rate (PR) was 68/min., blood pressure (BP) 140/86 mmHg, temperature 36.5°C, respiratory rate (RR) 10/min. Her investigations were Hb -8.8 gm%, total leucocyte count-12,400/mm3, serum Na+-112 meq/l (normal range 135-145 meq/l), serum K+-2.2 meq/l (normal range 3.5-5.5 meq/l). Her liver function tests, kidney function tests and chest X-ray were normal and ECG showed low voltage complexes. A sample for TFT was immediately sent. Abdominal ultrasound revealed a mass in right iliac fossa suggesting appendicular lump along with paralytic ileus. She was started on conservative management along with correction of electrolytes and active rewarming. Meanwhile her TFT showed severe hypothyroidism with T3 being 62 ng/dL (normal range 100-180 ng/ dL), T4-2.2 μg/dL (normal range 4-12 μg/dL) and TSH-18 μU/ ml (normal range 0.5-6 μU/ml). Her dose of eltroxin was elevated to 100 μg/day.\nHer abdominal distension increased over the next 48 hours and a contrast-enhanced CT scan of abdomen revealed intestinal perforation. She was immediately taken up for laparotomy. Preoperatively, the patient was still drowsy but stable hemodynamically.\nGeneral anesthesia was induced using rapid sequence induction. Immediately after induction, she had systolic hypotension (85 mmHg), managed with fast crystalloids. There was a further drop in her blood pressure after the abdomen was opened during surgery, necessitating dopamine infusion along with noradrenaline infusion. Her entire colon was found to be gangrenous and extended right hemicolectomy was done. Intravenous steroids were given. Surgery lasted for 2 hours and she was shifted to ICU for elective ventilation\nWhen received in ICU, patient was hypothermic (temperature 34.6°C) and hypotensive (systolic BP-68 mmHg). Rewarming was started with of warm fluids, bladder lavage with warm saline and electric blanket. Three litres of lactated ringer's solution was pushed intravenously. Adrenaline infusion was now added. This managed to maintain her systolic BP to around 85 mmHg. Unfortunately parental thyroxine was not available so we decided to give eltroxine tablet (500 μg) once daily via Ryle's tube. This along with aggressive antibiotic coverage, steroid supplementation and inotropic support gradually improved her blood pressure over the next 24 hours. Her TFT also showed marked improvement after 3 days. Her eltroxine was titrated to 150 μg twice a day now.\nOver the next 2 days, her inotropic support was gradually tapered off and stopped. Her eltroxin dose was also decreased to 100 μg twice a day. Finally on postoperative day 5, she was extubated and shifted to the postoperative ward.