A patient underwent thyroidectomy for Hyperthyroidism. Two days later he presented with features of thyroid storm. What is the most likely cause?(AIIMS November 2015. COMED K 2007)

Ans. d. Inadequate preoperative preparation (Ref: Schwartz 9/e p1355: Sabiston 19/e p897; Bailey 26/e p762, 25/e p786- 787; Harrison 18/e p2927)Thyrotoxic crisis (storm) is an acute exacerbation of hyperthyroidism. It occurs if a thyrotoxic patient has been inadequately prepared for thyroidectomy."Thyrotoxic crisis (storm): This is an acute exacerbation of hyperthyroidism. It occurs if a thyrotoxic patient has been inadequately prepared for thyroidectomy and is now extremely rare. Very rarely, a thyrotoxic patient presents in a crisis and this may follow an unrelated operation. Symptomatic and supportive treatment is for dehydration, hyperpyrexia and restlessness. This requires the administration of intravenous fluids, cooling the patient with ice packs, administration of oxygen, diuretics for cardiac failure, digoxin for uncontrolled atrial fibrillation, sedation and intravenous hydrocortisone. Specific treatment is by carbimazole 10-20 mg 6-hourly, LugoVs iodine 10 drops 8-hourly by mouth or sodium iodide Ig i.v. Propranolol intravenously (1--2 mg) or orally (40 mg 6-hourty) will block b-adrenergic effects. " --Bailey 26/e p762Thyroid Storm (Thyrotoxic crisis)It is an emergency due to decompensated hyperthyroidismQ.Treatment of Thyroid Storm (Thyrotoxic crisis)Non-selective beta--blocker (Propranolol):Most valuable measure in thyroid stormQ,In thyroid storm most of the symptoms are because of adrenergic over activity due to increased tissue sensitivity to catecholamines in hyperthyroidism.This increased sensitivity is due to increased number of beta receptorsQ.Quick relief is obtained by blocking beta-receptors.Propylthiouracil:Antithyroid drug of choice for thyroid stormQReduces hormone synthesis as well as peripheral conversion of T4 to T3QCorticosteroids (Hydrocortisone):Inhibits both release of thyroid hormone from the gland and peripheral conversion of T4 to T3QIodides (Potassium iodide or lopanoic acid):Used to inhibit further hormone releaseQ from the gland.Other Measures:Diltiazem, if tachycardia is not controlled by propranolol alone.Rehydration, anxiolytics, external cooling & appropriate antibiotics