INI-CET 2015 — Surgery

Q: A patient underwent thyroidectomy for hyperthyroidism. Two days later, the patient presented with features of thyroid storm. What is the most likely cause?

Inadequate preoperative preparation. ### Explanation **1. Why "Inadequate Preoperative Preparation" is correct:** The primary goal of preoperative management in hyperthyroidism (especially Graves' disease) is to achieve a **euthyroid state** before surgery. If a patient is not properly prepared with antithyroid drugs (like Carbimazole or Methimazole) and Beta-blockers, the thyroid gland remains hyperactive. Surgical manipulation of an overactive gland triggers a massive release of stored thyroid hormones (T3 and T4) into the circulation. This sudden surge precipitates a **Thyroid Storm**, a life-threatening hypermetabolic state characterized by hyperpyrexia, tachycardia, and cardiac failure. **2. Why other options are incorrect:** * **Poor antibiotic coverage:** While this increases the risk of surgical site infection or sepsis, it does not directly trigger the hormonal surge characteristic of a thyroid storm. * **Rough handling during surgery:** While excessive manipulation can exacerbate hormone release, it rarely causes a storm if the patient was adequately prepared and euthyroid. Preparation is the definitive preventive factor. * **Removal of parathyroid:** This leads to **hypocalcemia** (tetany, Chvostek’s/Trousseau’s signs), not thyroid storm. **3. Clinical Pearls for NEET-PG:** * **Lugol’s Iodine:** Often given 10 days preoperatively to decrease the **vascularity** and friability of the gland (Plummer’s effect). * **Drug of choice for Thyroid Storm:** **Propylthiouracil (PTU)** is preferred over Methimazole because it also inhibits the peripheral conversion of T4 to T3. * **Beta-blockers (Propranolol):** Essential to control adrenergic symptoms and also help inhibit peripheral T4 to T3 conversion. * **Burch-Wartofsky Point Scale:** Used clinically to diagnose and grade the severity of a thyroid storm. [Practice more Surgery PYQs on OnCourse]

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A patient underwent thyroidectomy for hyperthyroidism. Two days later, the patient presented with features of thyroid storm. What is the most likely cause?