Hyperthyroidism
Mon, 12/24/2007 - 17:34 — oxygen
Hyperthyroidism Listen to Audio Clinical causes Clinical manifestations Diagnosis Treatment
Preoperative management Intraoperative
management Postoperative mangement Clinical
causes: -Graves Disease -exogenous administration
-thyroiditis -toxic multinodular goiter -adenoma of
thyroid -tumor of pituitary Clinical manifestations:
-weight loss -muscle weakness -nervousness -heat
intolerance -diarhea -reflex (hyper-reflexia)
Diagnosis: Throid Function Test: -increased T3
-increased T4 (bound and unbound) -decreased TSH
Treatment: Medical treatment -propylthiouracil
-methimazole -sodium iodide -potassium
-propranolol -radioactive iodine (not for pregnant
females) Surgical treatment -subtotal thyroidectomy Indication: -large toxic multinodular goiter
-solitary toxic adenoma Preoperative management Elective surgery: -euthryoid with medical
treatment -normal thyroid function test -resting heart rate < 85 bpm -continue antithyroid
medications till a.m of surgery Emergency surgery: -attempt for CVS stability with esmolol
infusion Intraoperative management Induction: -induction agent of choice : thiopental may have
an exaggerated hypotensive response to induction due to: -hypovolemia -vasodilated Intubation:
intubate patient when deeply anesthetized to avoid: -tachycardia -hypertension -ventricular
dysrhythmia Systemic precautions: -ophthalmology: exopthalmus: therefore avoid corneal abrasions
-airway: avoid kinking, compression or obstruction of ETT: may require armored ETT -thyroid
mass: head elevation approx 15 - 20 degree to promote venous drainage and reduce amount of
bleeding -cardiac: avoid tachycardia, hypertension, ventricular dysrhythmias -hepatic: increased
drug metabolism therefore more prone to hepatic injury ex. halothane hepatitis -renal: may be prone
to renal toxicity ex. enflurane -NMJ: hyperthyroidism may be associated myopathies, myasthenia
gravis Postoperative management: Observe for potential postoperative complications: -thyroid
storm -recurrent laryngeal nerve (RLN) palsy -hematoma -hypoparathyroidism -pneumothorax
Thyroid storm: -change in mental status (agitation, delirium, coma) -tachycardia (treat with esmolol
infusion or propranolol 0.5 mg IV increments until heart rate is less than 100bpm) -hyperpyrexia
(treat with cooling blanket) recurrent laryngeal nerve palsy: acute -unilateral: hoarseness -bilateral:
stridor, aphonia, flacid paralysis adduction of vocal cords Hematoma: -may create tracheal/airway
compression and obstruction
Hypothyroidism
Tue, 12/25/2007 - 11:11 — oxygen
Hypothyroidism Listen to Audio Clinical causes Clinical manifestations Diagnosis Treatment
Preoperative management Intraoperative
management Postoperative management Clinical
causes: -Hashimotos thyroiditis -iodine deficiency
-radioactive iodine -antithyroid medications
-thyroidectomy -secondary hypothyroidism Clinical
manifestations -weight gain -cold intolerance
-muscle fatigue -lethargy -constipation -reflex
decreased (hyporeflexia) -depression Diagnosis:
Primary hypothyroidism: -decreased T3 -decreased
T4 -increased TSH Secondary hypothyroidism:
-decreased T3 -decreased T4 -decreased TSH Treatment: Oral replacement: -physiological effect
within few days -clinical improvement within several weeks Myxedema/emergency: -loading dose:
levothyroxine 300 - 500mg -maintenence doses: ex. levothyroxine 50 mg q day Preoperative
management: Elective surgery: -thyroid hormone level should be therapeutic Emergency surgery:
give thyroid hormone prior to procedure in patients with: -uncorrected severe hypothyroidism T4<
1mg/dL -myxedema coma Premedication: -may not be required due to the sedative nature of the
disease (lethargy, depression) -may be more prone to opiod induced respiratory depression
Intraoperative management: induction: ketamine may be considered induction agent of choice
Airway: may be difficult intubation due to large tongue CNS: same MAC requirements CVS:
senstive to cardiodepressant effects of volatile anesthetics due to: -decreased intravascular volume
therefore decreased preload -blunted baroreceptor response theferefore decreased HR -overall
decreased cardiac output Other possible intraoperative complications: -hypoglycemia
-hyponatremia -hypothermia -large tongue for difficult ventilation/intubation Postoperative
management May have delayed emergence/recovery from GA due to: -hypothermia -respiratory
depression -delayed/slowed drug biotransformation *therefore may require prolonged mechanical
ventilation *ketorolac may be preferred to opiod analgesia due to less risk of drug induced
respiratory depression