Simon Bourcier1, Maxime Coutrot1, Antoine Kimmoun2, Romain Sonneville3, Etienne de Montmollin4, Romain Persichini5, David Schnell6, Julien Charpentier7, Cécile Aubron8, Elise Morawiec9, Naïke Bigé10, Saad Nseir11, Nicolas Terzi12, Keyvan Razazi13, Elie Azoulay14, Alexis Ferré15, Yacine Tandjaoui-Lambiotte16, Olivier Ellrodt17, Sami Hraiech18, Clément Delmas19, François Barbier20, Alexandre Lautrette21, Nadia Aissaoui22, Xavier Repessé23, Claire Pichereau24, Yoann Zerbib25, Jean-Baptiste Lascarrou26, Serge Carreira27, Danielle Reuter28, Aurélien Frérou29, Vincent Peigne30,31, Pierre Fillatre32, Bruno Megarbane33, Guillaume Voiriot34, Alain Combes1,35, Matthieu Schmidt1,35. 1. Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, Paris, France. 2. Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, Vandoeuvre-les-Nancy, France. 3. Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, APHP, Paris, France. 4. Medical-Surgical Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France. 5. Medical-Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) de La Réunion, Felix-Guyon Hospital, Saint-Denis, La Réunion, France. 6. Service de Réanimation Polyvalente, CH d'Angoulême, Angoulême, France. 7. Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, APHP, Paris, France. 8. Department of Critical Care, Brest University Hospital, Brest, France. 9. Service de Pneumologie et Réanimation Médicale (Département "R3S"), Hôpital de la Pitié-Salpêtrière, APHP, Paris, France. 10. Medical Intensive Care Unit, Hôpital Saint-Antoine, APHP, Paris, France. 11. Critical Care Center, University Hospital of Lille, Lille University, Lille, France. 12. Department of Medical Intensive Care, CHU de Grenoble Alpes, Grenoble, France. 13. Medical Intensive Care Unit, CHU Henri-Mondor, APHP, Créteil, France. 14. Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France. 15. Medical-Surgical Intensive Carre Unit, CH de Versailles, Le Chesnay, France. 16. Medical Intensive Care Unit, Avicenne University Hospital, APHP, Bobigny, France. 17. Département de Médecine Intensive, Groupe Hospitalier Sud Île-de-France, Hôpital de Melun, Melun, France. 18. Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Marseille, France. 19. Intensive Care Unit, Anesthesia and Critical Care Department, Institut des Maladies Métaboliques et Cardiovasculaires, Rangueil University Hospital, Toulouse, France. 20. Medical Intensive Care Unit, CH Regional d'Orléans, Orléans, France. 21. Medical Intensive Care Unit, CHU Clermont-Ferrand, Clermont-Ferrand, France. 22. Department of Critical Care Unit, Hôpital Européen Georges-Pompidou (HEGP), APHP, Paris, France. 23. Intensive Care Unit, University Hospital Ambroise-Paré, APHP, Boulogne-Billancourt, France. 24. Intensive Care Unit, Poissy Saint-Germain-en-Laye Hospital, Poissy, France. 25. Department of Medical Intensive Care, Amiens University Hospital, Amiens, France. 26. Médecine Intensive Réanimation, CHU de Nantes, Nantes, France. 27. Medical-Surgical Intensive Care Unit, Saint-Camille Hospital, Bry-sur-Marne, France. 28. Medical-Surgical Intensive Care Unit, CH Sud Francilien, Corbeil, France. 29. Medical Intensive Care Unit, Hôpital Pontchaillou, CHU de Rennes, France. 30. Haute-Savoie Fire Department, Meythet, France. 31. Intensive Care Unit Metropole-Savoie Hospital, Chambery, France. 32. Medical-Surgical Intensive Care Unit, CH de Saint-Brieuc, Saint-Brieuc, France. 33. Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France. 34. Service de Pneumologie et Réanimation, Hôpital Tenon, APHP, Paris, France. 35. Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
Abstract
OBJECTIVES: Thyroid storm represents a rare but life-threatening endocrine emergency. Only rare data are available on its management and the outcome of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management and in-ICU and 6-month survival rates of patients with those most severe thyroid storm forms requiring ICU admission. DESIGN: Retrospective, multicenter, national study over an 18-year period (2000-2017). SETTING: Thirty-one French ICUs. PATIENTS: The local medical records of patients from each participating ICU were screened using the International Classification of Diseases, 10th Revision. Inclusion criteria were "definite thyroid storm," as defined by the Japanese Thyroid Association criteria, and at least one thyroid storm-related organ failure. MEASUREMENTS AND MAIN RESULTS: Ninety-two patients were included in the study. Amiodarone-associated thyrotoxicosis and Graves' disease represented the main thyroid storm etiologies (30 [33%] and 24 [26%] patients, respectively), while hyperthyroidism was unknown in 29 patients (32%) before ICU admission. Amiodarone use (24 patients [26%]) and antithyroid-drug discontinuation (13 patients [14%]) were the main thyroid storm-triggering factors. No triggering factor was identified for 30 patients (33%). Thirty-five patients (38%) developed cardiogenic shock within the first 48 hours after ICU admission. In-ICU and 6-month postadmission mortality rates were 17% and 22%, respectively. ICU nonsurvivors more frequently required vasopressors, extracorporeal membrane of oxygenation, renal replacement therapy, mechanical ventilation, and/or therapeutic plasmapheresis. Multivariable analyses retained Sequential Organ Failure Assessment score without cardiovascular component (odds ratio, 1.22; 95% CI, 1.03-1.46; p = 0.025) and cardiogenic shock within 48 hours post-ICU admission (odds ratio, 9.43; 1.77-50.12; p = 0.008) as being independently associated with in-ICU mortality. CONCLUSIONS: Thyroid storm requiring ICU admission causes high in-ICU mortality. Multiple organ failure and early cardiogenic shock seem to markedly impact the prognosis, suggesting a prompt identification and an aggressive management.
OBJECTIVES: Thyroid storm represents a rare but life-threatening endocrine emergency. Only rare data are available on its management and the outcome of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management and in-ICU and 6-month survival rates of patients with those most severe thyroid storm forms requiring ICU admission. DESIGN: Retrospective, multicenter, national study over an 18-year period (2000-2017). SETTING: Thirty-one French ICUs. PATIENTS: The local medical records of patients from each participating ICU were screened using the International Classification of Diseases, 10th Revision. Inclusion criteria were "definite thyroid storm," as defined by the Japanese Thyroid Association criteria, and at least one thyroid storm-related organ failure. MEASUREMENTS AND MAIN RESULTS: Ninety-two patients were included in the study. Amiodarone-associated thyrotoxicosis and Graves' disease represented the main thyroid storm etiologies (30 [33%] and 24 [26%] patients, respectively), while hyperthyroidism was unknown in 29 patients (32%) before ICU admission. Amiodarone use (24 patients [26%]) and antithyroid-drug discontinuation (13 patients [14%]) were the main thyroid storm-triggering factors. No triggering factor was identified for 30 patients (33%). Thirty-five patients (38%) developed cardiogenic shock within the first 48 hours after ICU admission. In-ICU and 6-month postadmission mortality rates were 17% and 22%, respectively. ICU nonsurvivors more frequently required vasopressors, extracorporeal membrane of oxygenation, renal replacement therapy, mechanical ventilation, and/or therapeutic plasmapheresis. Multivariable analyses retained Sequential Organ Failure Assessment score without cardiovascular component (odds ratio, 1.22; 95% CI, 1.03-1.46; p = 0.025) and cardiogenic shock within 48 hours post-ICU admission (odds ratio, 9.43; 1.77-50.12; p = 0.008) as being independently associated with in-ICU mortality. CONCLUSIONS: Thyroid storm requiring ICU admission causes high in-ICU mortality. Multiple organ failure and early cardiogenic shock seem to markedly impact the prognosis, suggesting a prompt identification and an aggressive management.