Thyroid storm/crisis

Prof. Sadqa Aftab

Consultant anesthetist cardiac
surgery dept CHK
A 18 yr old women 78 Kg was diagnosed as
Graves disease and treated with
propylthiouracil 250mg and propranolol
40mg twice daily.
After one year she was planned for
elective thyroidectomy, she had also
history of asthma with occasional use of
Inhaled Albuterol. On examination
Thyroid was slightly enlarged and Her
labs were within normal limit
On morning of surgery vitals and labs were
BP 134/74 mmHg
HR 100/min
Temp 37 C
Hb 11.4gm/dl
ECG sinus tachycardia
 No history of previous anesthesia or surgery
 All medication were withheld in morning on
advice of surgeon and tachycardia
attributed to anxiety before surgery
 Premedication's midazolam,
Induction
Propofol, fentanyl and Rocuronium
Maintenance
O2/N2O/isoflurane
 Thirty mins after incision during dissection
around thyroid gland HR increases to 110 to
120/min
 Additional bolus of fentanyl was given
 Sweating started with temp of 39 but end
tidal tidal CO2 was 30mmHg and soda lime
absorber does not indicate undue warmth
Management
 Metopropolol 1mg given while proponolol
avoided because of asthma
 Cooling measures with cooling and cold IV
fluids started & urinary catheter was
inserted
 Then Temp decrease to 38 C, SPO2 97%, BP
105-120/40-50 mmHg, HR 110/min
 Metopropolol was repeated on interval and
total of 10 mg was administered along with
repeated doses of fentanyl and Rocuronium
during surgery
 Subtotal thyroidectomy completed with
minimum blood loss
 Patient transferred to ICU
ICU management
 One hr later with vitals BP 145/65 mmHg, HR
108/min, Temp 37 C, R/R 23/ min, SPO2 98%,
 ABG PH 7.28, PaO2 209 mmHg ,
PCO2 48 mmHg, HCO3 22, BD -5 with 40%
Fio2 on spontaneous mode
 Reversal done with neostigmine and
glycopyrolate
 Patient was responsive to verbal command and
extubated after T piece trail
 Propylthiouracil was started HR came down to
100/min, patient was discharge to ward on
next day
Discussion
Thyroid storm/crisis in surgical patients
 Surgery
 Infection
 Trauma
 Overdose of thyroid replacement medication
 Usually occur 6-18 hrs postoperatively in
unprepared or inadequately prepared
patients
 But can happen intraoperatively mimicking
malignant hyperthermia
Clinical presentation fever, tachycardia,
profuse sweating, systolic hypertension
and widened pulse pressure, atrial
fibrillation. Restlessness and agitation,
CCF
Differential diagnosis include
anaphylactic reaction, malignant
hyperthermia, pheochromocytoma,
neuroleptic malignant syndrome (Unlike
MH, not associated with muscle rigidity,
elevated CPK, or marked degree or
lactic or respiratory acidosis)
Treatment if crisis occurs
1. ABC’s
2. General supportive measures cooling, cold
IV fluid, treatment of hypovolemia
3. IV propanolol (.5mg increments)/esmolol to
control heart rate until less than 100.
(Diminish metabolic effect of thyroid
hormones Proponolol drug of choice)
4. Propylthiouracil 250mg Q6 hours orally or
by NG tube Reducing secretion and
production of thyroid hormone
5. Sodium Iodide 1 gram over 12 hours
6. Treat underlying illness e.g correction of
any precipitating events (infection)
7. Cortisol is recommended if there is any
coexisting adrenal gland suppression
8. Treatment of possible thyroid crisis should
not await the arrival of confirmatory
thyroid function test
9. Mortality rate is approximately 20%
In Our case
Preoperatively
 Possibly patient was undertreated because
of absence of obvious sign and symptoms
 Antithyroid medications and beta-blockers
should be continued through the morning of
surgery.
 On day of surgery BP 134/74 mmHg, HR
100/min, Temp 37 C, Hb 11.4gm/dl
 Monitor shows ECG sinus tachycardia
Crisis precipitated
 With stress of anesthesia and surgery
 To Differentiate from malignant
hyperthermia (normal End tidal CO2,
absence of arrhythmias, skin flushing, ABG
with normal PaCO2, and absence of
Hypoxemia
Crisis managed
 Early intervention with B blocker prevented
disaster
Lesson to learn
1. Thyroid storm is uncommon but occur in
unprepared and inadequately treated
patients
2. Be careful especially in day case surgery
for hyperthyroid patient undergoing non
thyroid surgery
3. Brief period to assess and formulate plan of
anesthesia does not serve the patient well
4. Anesthetist should meticulously assess
euthyroid state of patient