Prognostic value of cortisol and thyroid function tests in poisoned patients admitted to toxicology ICU

doi:10.5847/wjem.j.1920-8642.2018.01.008

Abstract

Abstract:

BACKGROUND: Prognostic value of cortisol and thyroid function tests (TFTs) has previously been evaluated in medical ICUs. We aimed to evaluate prognostic efficacy of cortisol and TFTs in critically ill poisoned patients admitted to toxicology intensive care unit (ICU).
METHODS: In a prospective study of consecutively enrolled subjects admitted to the toxicology ICU, lab analyses included TFTs (total T3 and T4 as well as TSH) and cortisol levels drawn between 8 am-10 am during period of the first 24 hours post-ingestion/exposure. Simplified Acute Physiology Score II (SAPS II) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were recorded. All scores were compared to detect the best prognostic factor. Type of poisoning was also included.
RESULTS: In 200 patients evaluated, 129 were male and mean age was 31 years. In general, SAPS II, T4, and cortisol could prognosticate death. After regression analysis, only cortisol had such efficacy (P=0.04; OR=1.06; 95%CI=1.05-1.08; cut-off=42 μg/dL; sensitivity=70%; specificity=82%). Between aluminium phosphide (ALP)- and non ALP-poisoned patients, level of consciousness, mean arterial pressure, and cortisol level could prognosticate death in ALP poisoning (all Ps<0.001 in both uni and multivariate analyses). Median (interquartile range; IQR) GCS was 7 (6, 10) and 15 (8, 15) in non-ALP and ALP-poisoned patients (P<0.003). SAPS II and APACHE II could not prognosticate death at all.
CONCLUSION: Cortisol best prognosticated outcomes for subjects admitted to the toxicology ICU. Its level is higher in ALP-poisoned patients probably due to the higher stress while they remain conscious till the final stages of toxicity and are aware of deterioration of their clinical condition or may be due to their significantly lower blood pressures.

Key words: Prognosis, Intensive care unit, Cortisol, Thyroid function tests, Poisoning

Shahin Shadnia, Nasim Zaman, Hossein Hassanian-Moghaddam, Hamed Shafaroodi, Mina Padandar, Mohammad Hasan Rezaeizadeh. Prognostic value of cortisol and thyroid function tests in poisoned patients admitted to toxicology ICU[J]. World Journal of Emergency Medicine, 2018, 9(1): 51-55.

Figures/Tables 3

Table 1

Table 2

Table 3

Comparison of the ALP- and non ALP-poisoned patients

Variables	ALP (dead=8)	Others (dead=18)	P	ALP (alive=16)	Others (Alive=158)	P	ALP (total=24)	Others (total=176)	P
Cortisol	52.9±18.4 (17.4-63.4)	45.3±22.3 (4-63.4)	0.409	45.9±21.6 (0.5-63.4)	26.2±15.6 (0.85-63.4)	0.002	47.6±21.1 (0.85-63.44)	28.1±17.1 (0.52-63.44)	0.001
TSH	3.4 [0.6, 4.4] (0.5-9.8)	0.9 [0.6, 1.2] (0.4-20)	0.161	1 [0.6, 1.3] (0.4-2.5)	1 [0.7, 1.3] (0.2-17)	0.978	1.1 [0.6, 2.1] (0.4-9.8)	1 [0.7, 1.2] (0.2-20)	0.341
T3	1.3 [0.8, 1.7] (0.7-1.8)	1.3 [0.8, 1.7] (0.6-36.5)	1	1.2 [1, 1.6] (0.8-2)	1.3 [1, 1.6] (0.6-47.3)	0.862	1.2 [0.9, 1.7] (0.7-2)	1.3 [1, 1.6] (0.6-47.3)	0.779
T4	5.5 [3.3, 5.9] (1.8-10.8)	6.3 [5.3, 7.4] (4.9-10.4)	0.071	7.3 [6.3, 7.6] (4.5-11.3)	7.2 [6.1, 8.1] (0.9-74)	0.985	6.5 [5.4, 7.6] (1.8-11.3)	7.2 [6, 8] (0.9-74)	0.223
APACHE	13.1±6.1	15.5±5.4	0.255	18±5.7	20.9±6	0.096	14.7±6.6	16±5.7	0.294
SAPS	33.8±11.8	31.9±11.3	0.227	38±15.3	45.9±14.8	0.544	33.9±12.8	35.1±12.7	0.693
Systolic blood pressure	85.9±10.5 (76, 110)	115.8±27.5 (75-174)	0.001	104.0±18.8 (80-140)	118.4±24.8 (50-228)	0.025	97.9±18.4 (76-140)	118.1±25.0 (50-228)	0.001
Diastolic blood pressure	54.6±15.0 (39-90)	73.5±18.2 (50-115)	0.017	61.1±13.6 (40-90)	73.4±15.7 (30-130)	0.003	58.9±14.1 (39-90)	73.4±15.9 (30-130)	0.001
Mean arterial pressure	65.0±13.6 (51-97)	87.5±20.0 (58, 135)	0.008	75.2±14.5 (57-107)	88.4±18.0 (37-163)	0.005	71.8±14.7 (51-107)	88.3±18.1 (37-163)	0.001
Pulse rate	87.7±28.4 (50-125)	107.5±28.0 (60-164)	0.109	106.8±27.0 (62-167)	98.6±22.6 (48-160)	0.170	100.4±28.4 (50-167)	99.5±23.2 (48-164)	0.850
Loss of consciousness??	3 (37.5)	15 (83.3)	0.060	4 (25)	138 (87.3)	0.001	7 (29.2)	153 (86.9)	0.001
Agitation?	0	2 (11.1)	1	3 (18.8)	8 (5.1)	0.067	3 (12.5)	10 (5.7)	0.193
Hypoventilation?	0	3 (16.7)	0.529	2 (12.5)	20 (12.7)	1	2 (8.3)	23 (13.1)	0.745
Seizure?	0	0	-	0	8 (5.1)	1	0	8 (4.5)	0.599
Hypoglycemia?	1 (12.5)	1 (5.6)	0.529	0	3 (1.9)	1	1 (4.2)	4 (2.3)	0.476

Table 3

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Variables	Results
Non-normal distribution, Median [IQR] (range)
Glasgow Coma Scale	8 [6, 13] (3-15)
APACHE II score	15 [12, 14] (4-38)
Respiratory rate (beats/minute)	16 [14, 20] (4-50)
Time of ingestion/exposure to hospital presentation (h)	4 [2, 10] (0.5-24)
T3 (ng/dL)	1.3 [1, 1.6] (0.6-47.3)
T4 (μg/dL)	7.2 [6, 7.9] (0.9-74)
Thyroid-stimulating hormone (TSH) (μIU/mL)	1 [0.7, 1.3] (0.2-20)
Hospital stay (days)	4 [3, 8] (1-60)
Body temperature (℃)	37 [36.7, 37.1] (35.5-39.2)
Normal distribution, Mean±SD (range)
Systolic blood pressure (mmHg)	116±25 (50-228)
Diastolic blood pressure (mmHg)	72±16 (30-130)
Mean arterial pressure (mmHg)	86±18.5 (37-163)
Pulse rate (beats/minute)	100±24 (48-167)
SAPS score	34.9±12.6 (8-75)
Cortisol level (mg/dL)	30.7±18.9 (0.5-63.4)

Variable	MAP<65 (n=26)	MAP≥65 (n=174)	P, mean difference [95% CI]
Cortisol	39.36±21.22 (1.14-61.44)	29.33±18.22 (0.52-61.44)	0.011, 10 [2.3-17.8]
TSH	0.85 [0.6, 1.6]	1 [0.7, 1.3]	0.651
T3	1.35 [0.9, 1.7] (0.7-36.50)	1.2 [1, 1.6] (0.6-47.3)	0.456
T4	7 [5.57, 8.77] (3.30-11.30)	7.20 [6.00, 7.87] (0.90-74.00)	0.773

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