Risk of perioperative thyroid storm in hyperthyroid patients: a systematic review

Abstract

Background: Thyroid storm is a feared complication in patients with hyperthyroidism undergoing surgery. We assessed the risk of thyroid storm for different preoperative treatment options for patients with primary hyperthyroidism undergoing surgery. Methods: Pubmed, EMBASE, and The Cochrane Library were searched systematically for all studies reporting on adult hyperthyroid patients undergoing elective surgery under general anaesthesia. Selected studies were categorised based on preoperative treatment: no treatment, antithyroid medication (thionamides), iodine, b-blocking medication, or a combination thereof. Treatment effect, that is restoring euthyroidism, was extracted from the publications if available. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) or the Cochrane Risk of Bias tool for randomised studies. Results: The search yielded 7009 articles, of which 26 studies published between 1975 and 2020 were selected for critical appraisal. All studies had moderate to critical risk of bias, mainly attributable to risk of confounding, classification of intervention status, and definition of the outcome. All studies reported on thyroidectomy patients. We found no randomised studies comparing the risk of thyroid storm between treated and untreated patients. Cases of thyroid storm were reported in all treatment groups with incidences described ranging from 0% to 14%. Conclusion: Evidence assessing the risk of perioperative thyroid storm is of insufficient quality. Given the seriousness of this complication and the impossibility of identifying patients at increased risk, preoperative treatment of these patients remains warranted.

Hyperthyroidism

“…Presenting symptoms may include fever, tachycardia, heart failure, atrial fibrillation, and various central nervous system abnormalities. Thyroid storm may be precipitated by surgery, amiodarone use, or discontinuation of antithyroid drugs . Diagnostic criteria have been published by Burch and Wartofsky and by the Japanese Thyroid Association .…”

Impending tyroid storm

“…A history of associated hyperthyroidism (Grave's disease or toxic multinodullar goiter) is helpful in guiding the diagnosis. In patients with suspected thyroid crisis, look for precipitating factors that might induce thyroid storm (de Mul et al, 2021). Some specific clinical characteristics that strengthen the suspicion of a patient having a thyroid crisis are high fever, tachycardia, nausea, agitation and changes in mental status.…”

Undiagnosed Thyrotoxicosis Storm in a Patient Presenting With a Perioperative Sinus Tachycardia and Hypertensive Crisis After Induction of Anesthesia for Emergent Bipolar Hip Hemiarthroplasty After Traumatic Femur Neck Fracture: A Case Report

“…It is worth mentioning that the treatment of moderate to severe hyperthyroidism prior to urgent surgeries, although must be attempted to decrease the chance of developing thyroid storm, it does not always prevent it. In a systematic review by de Mul et al, the risk of the perioperative storm in hyperthyroid patients was still present even in a cohort treated with a triple combination of medication before the operation [ 17 ]. Thus, the anesthetist must stay vigilant and prepared to deal with the situation at any given time perioperatively.…”