Thyroid storm is a bit of a zebra. It can mimic a variety of common conditions (e.g. sepsis, delirium, heart failure). Unfortunately, if you're not looking for it, you probably won't find it. Once identified, an organized multimodal treatment regimen will generally get the job done. But be careful – these patients may have varying physiology, so blindly following the same rubric for every single patient isn't the answer.
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The IBCC chapter is located here.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Hi Josh
Thanks for this post.
I understand that this question doesn’t directly relate to the post, but under what circumstances would you check TFTs on the critical care patient.
My hospital pushes back on requests a lot (much of the lab’s work comes from the community requests for TFTs) and our chief biochemist considers it a waste of time because of the difficulties of interpretation in the context of sick euthyroid disease. This has resulted in very few requests being made because of the cynicism around requests being declined.
What’s your practice pattern for this on the general Critical Care patient?
If you suspect thyroid storm then thyroid function labs are mandatory, there’s no other way around this. Since this is a mimicker, you’re going to need to check a lot of TFTs to find a patient with thyroid storm. That’s OK and it’s better than missing someone with storm.
Most thyroid labs in the ICU will be slightly abnormal, the approach to this is generally to ignore it. So you’re basically fishing for labs which are definitively and markedly abnormal. Overall checking thyroid function labs is fine, but you have to be willing to ignore the mildly abnormal ones.
We will eventually have an entire chapter on sick euthyroid syndrome & thyroid labs in the ICU. It’s a pretty interesting topic.