In severe, refractory thyroid storm, extracorporeal blood purification is used to reduce circulating thyroid hormone levels and stabilise the patient. When this approach does not produce sufficient clinical improvement, a further escalation step is indicated.
The preceding step used therapeutic plasmapheresis (TPE) combined, where indicated by haemodynamic instability or severe complications, with continuous hemodiafiltration (CHDF). The required goals — reduction in free triiodothyronine (FT3) and free thyroxine (FT4) levels and clinical improvement — were not achieved.
When extracorporeal therapy fails to produce adequate stabilisation, a direct surgical intervention has been reported as the next management step for patients who continue to deteriorate — the structured criteria and procedural details are in the full protocol.