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Thyroid Storm in the ICU

A Retrospective Multicenter Study

Bourcier, Simon MD1; Coutrot, Maxime MD1; Kimmoun, Antoine MD, PhD2; Sonneville, Romain MD, PhD3; de Montmollin, Etienne MD4; Persichini, Romain MD5; Schnell, David MD6; Charpentier, Julien MD7; Aubron, Cécile MD, PhD8; Morawiec, Elise MD, PhD9; Bigé, Naïke MD, PhD10; Nseir, Saad MD, PhD11; Terzi, Nicolas MD, PhD12; Razazi, Keyvan MD13; Azoulay, Elie MD, PhD14; Ferré, Alexis MD15; Tandjaoui-Lambiotte, Yacine MD16; Ellrodt, Olivier MD17; Hraiech, Sami MD, PhD18; Delmas, Clément MD19; Barbier, François MD, PhD20; Lautrette, Alexandre MD, PhD21; Aissaoui, Nadia MD, PhD22; Repessé, Xavier MD23; Pichereau, Claire MD24; Zerbib, Yoann MD25; Lascarrou, Jean-Baptiste MD26; Carreira, Serge MD27; Reuter, Danielle MD28; Frérou, Aurélien MD29; Peigne, Vincent MD30,31; Fillatre, Pierre MD32; Megarbane, Bruno MD, PhD33; Voiriot, Guillaume MD, PhD34; Combes, Alain MD, PhD1,35; Schmidt, Matthieu MD, PhD1,35

doi: 10.1097/CCM.0000000000004078
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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.

1Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, Paris, France.

2Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, Vandoeuvre-les-Nancy, France.

3Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, APHP, Paris, France.

4Medical-Surgical Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France.

5Medical-Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) de La Réunion, Felix-Guyon Hospital, Saint-Denis, La Réunion, France.

6Service de Réanimation Polyvalente, CH d’Angoulême, Angoulême, France.

7Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, APHP, Paris, France.

8Department of Critical Care, Brest University Hospital, Brest, France.

9Service de Pneumologie et Réanimation Médicale (Département “R3S”), Hôpital de la Pitié-Salpêtrière, APHP, Paris, France.

10Medical Intensive Care Unit, Hôpital Saint-Antoine, APHP, Paris, France.

11Critical Care Center, University Hospital of Lille, Lille University, Lille, France.

12Department of Medical Intensive Care, CHU de Grenoble Alpes, Grenoble, France.

13Medical Intensive Care Unit, CHU Henri-Mondor, APHP, Créteil, France.

14Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France.

15Medical-Surgical Intensive Carre Unit, CH de Versailles, Le Chesnay, France.

16Medical Intensive Care Unit, Avicenne University Hospital, APHP, Bobigny, France.

17Département de Médecine Intensive, Groupe Hospitalier Sud Île-de-France, Hôpital de Melun, Melun, France.

18Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Marseille, France.

19Intensive Care Unit, Anesthesia and Critical Care Department, Institut des Maladies Métaboliques et Cardiovasculaires, Rangueil University Hospital, Toulouse, France.

20Medical Intensive Care Unit, CH Regional d’Orléans, Orléans, France.

21Medical Intensive Care Unit, CHU Clermont-Ferrand, Clermont-Ferrand, France.

22Department of Critical Care Unit, Hôpital Européen Georges-Pompidou (HEGP), APHP, Paris, France.

23Intensive Care Unit, University Hospital Ambroise-Paré, APHP, Boulogne-Billancourt, France.

24Intensive Care Unit, Poissy Saint-Germain-en-Laye Hospital, Poissy, France.

25Department of Medical Intensive Care, Amiens University Hospital, Amiens, France.

26Médecine Intensive Réanimation, CHU de Nantes, Nantes, France.

27Medical-Surgical Intensive Care Unit, Saint-Camille Hospital, Bry-sur-Marne, France.

28Medical-Surgical Intensive Care Unit, CH Sud Francilien, Corbeil, France.

29Medical Intensive Care Unit, Hôpital Pontchaillou, CHU de Rennes, France.

30Haute-Savoie Fire Department, Meythet, France.

31Intensive Care Unit Metropole-Savoie Hospital, Chambery, France.

32Medical-Surgical Intensive Care Unit, CH de Saint-Brieuc, Saint-Brieuc, France.

33Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France.

34Service de Pneumologie et Réanimation, Hôpital Tenon, APHP, Paris, France.

35Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Kimmoun received funding from lecturing for MSD, Gilead, and Baxter. Further relationships with industry can be found on https://www.transparence.sante.gouv.fr. Dr. Azoulay’s institution received funding from Fisher & Paykel and Gilead, and he received funding from Pfizer, Baxter, MSD, Alexion, and Ablynx. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Matthieu Schmidt, MD, PhD, Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, 47, bd de l’Hôpital, 75651 Paris Cedex 13, France. E-mail: matthieu.schmidt@aphp.fr.

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