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Wednesday, 11 December 2013

Thyroid disease: Euthyroid sick syndrome as a result of Sepsis - Treatments in conventional medicine perspective

Euthyroid sick syndrome
Euthyroid sick syndrome is defined as a condition of  low T3 low T4 syndrome. According ot the study by the Mayo Clinic, in  other word this is the abnormalities of thyroid hormone concentrations seen commonly in a wide variety of nonthyroidal illnesses, resulting in low triiodothyronine, total thyroxine, and thyroid stimulating hormone concentrations(a). Decreased triiodothyronine (T3) levels are most common. Patients with more severe or prolonged illness also have decreased thyroxine (T4) levels. Serum reverse T3 (rT3) is increased. Patients are clinically euthyroid and do not have elevated thyroid-stimulating hormone (TSH) levels(b). Causes of euthyroid sick syndrome include a number of acute and chronic conditions, including pneumonia, fasting, starvation, sepsis, trauma, cardiopulmonary bypass, malignancy, stress, heart failure, hypothermia, myocardial infarction, chronic renal failure, cirrhosis, and diabetic ketoacidosis and inflammatory bowel disease(c). Others, in the study of classified SES into 3 subgroups according to the different alterations seen in the values of T3, T4, FT3, FT4, TSH, rT3 and TBG suggested that in SES type I the diseases seen, in order of frequency, were: obstructive chronic bronchopneumopathy with acute respiratory failure, diabetic ketoacidosis, neoplasms, ischemic heart disease, cardiac failure, chronic renal failure, liver diseases, acute cerebral vasculopathies, sepsis and collagenopathies. The disease seen in the 2 cases of SES type II was obstructive chronic bronchopneumopathy with acute respiratory failure. In SES type III the diseases seen were, in order of frequency: diabetic ketoacidosis, lung diseases, ischemic heart disease, cardiac failure, peripheral arteriopathies, acute cerebral vasculopathies, neoplasms, liver diseases, acute renal failure(d).
Treatments
Treatments
E.1. Treatments in conventional medicine perspective
1. Antibiotics  
Most case of sepsis are treated with combination of two or three antibiotics given at the same time.
High doses of vancomycin were administered in order to rescue patients from septic shock. Plasma drug concentration dropped while clinical condition of patients worsened. Conversely, drug levels increased spontaneously once the infection was reverted. The theoretical model provided greater insight into pharmacokinetic features related with the use of vancomycin in septic patients(58). Other study indicated that patients with sepsis do not seem to have the same level of impairment of tissue distribution as described for patients with septic shock. A 25% lower dose of piperacillin administered by continuous infusion seems to maintain higher trough concentrations compared with standard bolus dosing. It is likely that the clinical advantages of continuous infusion are most likely to be evident when treating pathogens with high minimum inhibitory concentration, although without therapeutic drug monitoring and subsequent dose adjustment, infusions may never achieve target concentrations of organisms with very high minimum inhibitory concentrations in a small number of patients(59).
 
2. IV Fluids
In the study to determine the clinical and pharmacokinetic differences between continuous and intermittent dosing in patients with severe sepsis, found that continuous administration of beta-lactam antibiotics achieved higher plasma antibiotic concentrations than intermittent administration with improvement in clinical cure. This study provides a strong rationale for further multicenter trials with sufficient power to identify differences in patient-centered endpoints(60). Other study suggested that routine use of prolonged infusion of time-dependent antibiotics for the empiric treatment of gram-negative bacterial infections offers no advantage over intermittent infusion antibiotic therapy with regard to treatment success, mortality, or hospital length of stay. These results were confirmed after controlling for potential confounders in a multivariate analysis(61).

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(a) http://www.ncbi.nlm.nih.gov/pubmed/9086580
(b) http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/thyroid_disorders/euthyroid_sick_syndrome.html
(c) http://en.wikipedia.org/wiki/Euthyroid_sick_syndrome
(d) http://www.ncbi.nlm.nih.gov/pubmed/8028742
(1) http://clinicalcases.org/2004/05/sick-euthyroid-syndrome-in-patient-with.html
(58) http://www.ncbi.nlm.nih.gov/pubmed/18397685.
(59) http://www.ncbi.nlm.nih.gov/pubmed/19237898 
(60) http://www.ncbi.nlm.nih.gov/pubmed/23074313 
(61) http://www.ncbi.nlm.nih.gov/pubmed/23341160