Plasma exchange and early thyroidectomy in thyroid storm requiring extracorporeal membrane oxygenation

Abstract

Summary Thyroid storm with multi-organ failure limits the use of conventional treatment. A 44-year-old male presented with thyroid storm and experienced cardiovascular collapse after beta-blocker administration, with resultant fulminant multi-organ failure requiring inotropic support, mechanical ventilation, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy. Hepatic and renal failure precluded the use of conventional thyroid storm treatment and early plasma exchange was instituted. The patient underwent emergency thyroidectomy after four effective exchanges, with subsequent rapid reversal of multi-organ failure. The challenges of institution of plasma exchanges with ongoing ECMO support, dialysis and timing of thyroidectomy are discussed. This case highlights the important role of early therapeutic plasma exchange (TPE) as an effective salvage therapy for lowering circulating hormones and stabilization of patients in preparation for emergency thyroidectomy in patients with thyroid storm and fulminant multi-organ failure. Learning points: Administration of beta-blockers in thyroid storm presenting with congestive cardiac failure may precipitate cardiovascular collapse due to inhibition of thyroid-induced hyperadrenergic compensation which maintains cardiac output. TPE can be an effective bridging therapy to emergency total thyroidectomy when conventional thyroid storm treatment is contraindicated. End-organ support using ECMO and CRRT can be combined with TPE effectively in the management of critically ill cases of thyroid storm. The effectiveness of plasma exchange in lowering thyroid hormones appears to wane after 44–48 h of therapy in this case, highlighting the importance early thyroidectomy.

Therapeutic plasma exchange for control of thyroid storm

“…26 When used with TPE, case reports have showed clinical improvement and a reduction of FT4 by 44% to 80% and TRAb by 70% after 3 to 4 days of CRRT and TPE. [27][28][29] The only case report of CRRT used in isolation demonstrated a reduction of FT4 by 80% and near normalization of FT4 after 1 week of CRRT. 26 The mechanism by which CRRT reduces thyroid hormone and leads to clinical improvement is unclear.…”

“…26 Most patients in these case reports had multiorgan failure and the main indications for initiating CRRT was fluid removal or oliguric renal failure. 26,27 CRRT may be combined concurrently with TPE [27][28][29] or in isolation. 26 When used with TPE, case reports have showed clinical improvement and a reduction of FT4 by 44% to 80% and TRAb by 70% after 3 to 4 days of CRRT and TPE.…”

“…CRRT may be combined concurrently with TPE 27‐29 or in isolation 26 . When used with TPE, case reports have showed clinical improvement and a reduction of FT4 by 44% to 80% and TRAb by 70% after 3 to 4 days of CRRT and TPE 27‐29 . The only case report of CRRT used in isolation demonstrated a reduction of FT4 by 80% and near normalization of FT4 after 1 week of CRRT 26 …”

Description of parallel and sequential configurations for concurrent therapeutic plasma exchange and continuous kidney replacement therapy in adults

“…For example, we have recently published two case reports of patients with thyroid storm who presented with multi-organ failure and required CKRT, TPE and extracorporeal membrane oxygenation before they could undergo thyroidectomy. 4,5 Moreover, CKRT by definition is a therapy that is designed to be delivered continuously over 24 hours. In critically ill patients, interrupting CKRT to accommodate a session of TPE may compromise CKRT dose delivered.…”

“…In some other cases TPE‐CKRT may be required to bridge patients to a definitive treatment. For example, we have recently published two case reports of patients with thyroid storm who presented with multi‐organ failure and required CKRT, TPE and extracorporeal membrane oxygenation before they could undergo thyroidectomy 4,5 . Moreover, CKRT by definition is a therapy that is designed to be delivered continuously over 24 hours.…”