Anesthesia

and
Thyroid disease
By:-
NAOL G. (Msc in ACA)

may 2023

06/30/2024 Lecture on anesthesia for thyroid 1

 OUT LINE
Objectives

Introduction

Pathophysiology of thyroid and parathyroid

Perioperative management of thyroid surgery

Complications of thyroid surgery

Summery
Reference

06/30/2024 Lecture on anesthesia for thyroid 2

 objectives
At the end of these session students will be able to:-
Describe the pathophysiology of thyroid and parathyroid gland

Discuss perioperative management of thyroid surgery

Describe the anesthetic techniques and choice of drugs

Manage the complications of thyroid surgery

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 Anatomy of thyroid

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 Anatomy of thyroid
 Anatomy- Rt lobe, Lt lobe and isthmus
 Blood supply and drainage
 Superior thyroid artery arising from the external
carotid artery, and the inferior thyroid artery
branching from the thyrocervical trunk
 Venous drainage is carried by the superior, middle,
and inferior thyroid veins

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 cont.
 Nerve supply
1. Superior Laryngeal Nerve
Motor supply to cricothyroid muscle
(external branch)
Internal branch provides sensation above the
vocal cords including to epiglottis
2. Recurrent Laryngeal Nerve
Sensation below vocal cords
 Postop assessment after thyroidectomy is via
laryngoscopy & having pt phonate letter “e”
 Recurrent laryngeal n. & external motor branch
of superior laryngeal n. close to thyroid gland
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 Nerve injury
• External branch of SLN provides motor innervation to cricothyroid muscle
• Cricothyroids are muscles involved in laryngospasm (mediated by ext. SLN
• The cricothyroids adduct and tense the true vocal cords
• Injury of SLN causes possible risk for aspiration and hoarseness
• Selective RLN injury to abductor fibers: (1) hoarseness (2) bilateral injury
obstruction
• Hoarseness is caused either by unilateral RLN damage or SLN damage
• Laryngospasm after thyroidectomy results from hypocalcemia secondary
to hypoparathyroidism after inadvertent removal of parathyroid glands
•06/30/2024
Laryngeal muscles are very sensitive to decreased calcium
Lecture on anesthesia for thyroid 7
 Thyroid Masses
• As large as 2kg
• Esophageal compression causing dysphagia
• Tracheal compression – possible inspiratory stridor
• If mass extends into substernal region:
– SVC obstruction
– Major airway obstruction
– Cardiac compression
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 Thyroid Physiology
 Thyroid hormones

– T4 & T3 in blood bind reversibly

to proteins
– Only small amount, the free
fraction is biologically active
– Stimulate virtually all metabolic
processes, synthetic & catabolic
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 Control of thyroid hormones secretions
 Hypothalamus (TRH)  Anterior pituitary gland (TSH)
 (+) thyroid gland  (+) THs via cAMP dependent
mechanism
THs  -ve feed back mechanism to Hypothalamus in
order to inhibit (TRH) secretion to anterior pituitary gland
THs  also -ve feed back mechanism to Anterior
pituitary gland in order to inhibit responsiveness to
Hypothalamus (TRH)
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 Thyroid Disorders

 Thyroid hormone has two major

functions
– It increases the metabolic rate
and protein synthesis
– It is necessary for growth and
development

11
06/30/2024 Lecture on anesthesia for thyroid
 Diagnosis

• Normal TSH 0.4 – 5.0 mU/L

• Subclinical hyperthyroidism: TSH 0.1-0.4, normal FT3 & FT4
• Overt hyperthyroidism: TSH < 0.03, elevated FT3 & FT4
• Thyroid storm: TSH <0.01
• Subclinical hypothyroidism: TSH 5-10, normal FT3 & FT4
• Overt hypothyroidism: TSH >20 (up to 400), reduced T3, T4

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 Indications for thyroid surgery
• Thyroid malignancy
• Hyperthyroidism resistant to medical management
• Thyroid secreting adenomas(solitary nodule)
• Toxic Multinodular Goiter
• Goiters that produce obstructive symptoms
• Hashimoto’s thyroiditis and Iodine deficiency
• Retrosternal
• Cosmetic and Anxiety
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 History - Concerns
 Thyroid status
 Associated complications

– AF
– Other auto-immune conditions
 Dyspnoea (especially positional) & Dysphagia
 Medications & effects

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 Examination - Concerns
 Thyroid status
 Goiter

– Tracheal deviation
– SVC obstruction
 Airway

– Routine examination? Stridor?

– Retrosternal extension
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 Investigation
 Blood test
 CXR
 CT scan
 Nasendoscopy
 Respiratory flow volume loop

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 Optimisation
 Elective work should be postponed until the patient is euthyroid
 On the day of surgery, usual antithyroid medications should be
administered except for Carbimazole
 Anticholinergics?
 Acute preparation of thyrotoxic patients involves:
 Iodine and corticosteroids
 Beta blockade
 Intravenous hydration and active cooling if necessary

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 Cont.
– Inhibit hormone

Give synthesis antithyroid drug (PTU or methimazole), though limited

effect if for < 2 wks
– Prevent hormone release e.g, potassium, sodium iodide

Give iodide 2-3 hrs after antithyroid drug

– Anti adrenergic over activity B-blocker, preferably propranolol and also
decrease the peripheral conversion of T4 to T3
– Glucocorticoids – dexamethasone 2mg iv q6 hours – decreases hormone
06/30/2024 release & conversion of T4 toon anesthesia
Lecture T3 for thyroid 18
 Preparation
 Difficult Airway Plan
May require discussion with the surgeon and radiologist
Malignancy
- Cord palsies are likely, Distortion & rigidity of surrounding structures
- Tumour can produce obstruction anywhere from glottis to carina
Significant respiratory symptoms or >50% narrowing on CXR or
lateral thoracic inlet view
Coexisting predictors of difficult intubation
 Consider second experienced anaesthetist
 Prepare facial protection & ETT tapes
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Options to secure the airway for complicated thyroid
surgery
1. Induction in the semi-supine or sitting position
2. Inhalation induction with sevoflurane or halothane
3. Fibreoptic intubation
4. Tracheostomy under local anaesthetic
5. Ventilation through a rigid bronchoscope
– It is a backup option when attempts to pass an ETT fail

6. LMA - may be difficult to place in patients with laryngeal displacement

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 Induction
• Consider inhalational induction
• Consider L.A spray to cords
• Adequate paralysis before passing ETT
• Consider superficial cervical plexus block or asking surgeons to infiltrate
before incision
• Protect & Position patient

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 Cont.
• Drugs:

– Avoid stimulating the sympathetic nervous system (SNS)

• Ketamine, pancuronium, atropine, ephedrine, epinephrine

– Avoid anticholinergic drugs (i.e. atropine) – precipitates tachycardia and alters heat-
regulating mechanisms
– NMBD: Hyperthyroid patients may also have coexisting muscle disease (i.e.
myasthenia gravis) w/ reduced requirement for NMBD
– Reversal of muscle relaxants: avoid atropine; use glycopyrrolate

– Hypotension: direct-acting vasopressor (phenylephrine) preferrred

06/30/2024 • Avoid ephedrine, epinephrine,
Lecturenorepinephrine
on anesthesia for thyroid & dopamine 22
 Maintenance

• Adequate muscle relaxation & depth of anaesthesia

– No coughing / bucking!
• Minimize intra-thoracic positive pressure
• Analgesia +/- anti-emesis
• Dexamethasone if available

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 Emergence & Recovery
• Plan your extubation as per DAS
• Ensure full reversal prior to extubation
• L.A infiltration if not already done
• Post op analgesia

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 Complications
• AIRWAY
 Hemorrhage with tracheal compression

– Bleed from branches of inferior thyroid or superior thyroid artery

– First line tx: Hematoma evacuation

 Tracheomalacia

 Recurrent laryngeal nerve palsies – airway obstruction

• Damage to motor branch of superior laryngeal n

– innervates inferior pharyngeal constrictor & cricothyroid muscles -> limits
06/30/2024
force of one’s voice Lecture on anesthesia for thyroid 27
 Cont.
• Other
– Hypocalcaemia- within 24-48 hours post-op
• Anxiety, circumoral numbness, tingling of fingers, muscle cramps,
Chvostek’s & Trousseau’s sign
• Stridor to laryngospasm
• Tx : Calcium gluconate or calcium chloride 1gm IV
– Thyroid storm
– Pneumothorax
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Thyroid storm
• Be prepared for thyroid storm in poorly-controlled pt for emergency
surgery
• Establishing adequate anesthesia depth important
• Regional anesthesia – may be preferred technique
• Premedicate: Barbiturate, benzodiazepine and/or narcotic
• Induction: Thiopental decreases T4 to T3 conversion. Slight advantage
• Eye protection in proptosis – lubricant, eye pads

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 Thyroid Storm
• Life-threatening hyperthyroidism – Medications:
(mortality 20%), precipitated by • Titrate HR to < 90 bpm with
trauma, infection, illness or surgery propranolol, labetalol
• Most often in post-op period in poorly • Dexamethasone 2mg q6 hours
treated pts for emergency surgery or Cortisol 100-200mg q8 hours
• Presentation: • Antithyroid drugs (PTU)
– Extreme anxiety, fever, tachycardia, • For Afib: b-blocker or digitalis
CV instability, altered • For circulatory shock: direct
consciousness vasopressor (i.e. phenylephrine)
• Treat: decrease thyroid hormone &
supportive care
– IVF
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 Hypothyroidism

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Hypothyroidism causes cretinism in the infant or child and myxedema in the
adult. The large tongue of the patient with cretinism is the most important
consideration
06/30/2024
because it may make airway management difficult.
Lecture on anesthesia for thyroid 34
 Anesthetic concerns

 Three major concerns for the hypothyroid patient in the perioperative

period are:
(1) Intraoperative hypothermia,
(2) Delayed or impaired drug metabolism, and
(3) Cardiovascular instability and/or collapse

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 Cont.
Preoperative : Possible adverse responses of the hypothyroid patient
during the preoperative period
 ↑ Sensitivity to depressant
 Hypodynamic CVS (↓ HR,↓ CO, ↓ B/P)
 Slowed metabolism of drugs
 Un responsive baroreceptor reflexes
 Impaired ventilatory responses to arterial hypoxemia or hypercarbia
 Delayed gastric emptying time
 Hyponatremia, Hypothermia, Anemia, Hypoglycemia, Adrenal
insufficiency

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 Anesthetic management
Preoperative :
 Patients with uncorrected severe hypothyroidism (T4 < 1 mg/dL) or
myxedema coma should not undergo elective surgery and should be treated
with thyroid hormone prior to emergency surgery
 Patients who have been rendered euthyroid may receive their usual dose of
thyroid medication on the morning of surgery
 Supplemental cortisol may be considered
 Metoclopramide because of their decreased gastric-emptying times
06/30/2024
Supplemental cortisol may be considered
Lecture on anesthesia for thyroid 37
 Cont.
Intraoperative
Induction
 Ketamine has been proposed as the ideal induction agent
 Be careful with barbiturates & benzodiazepines -> CV depression
 Difficult intubation b/c of large tongue
 Co-excising skeletal muscle weakness could be associated with an
exaggerated muscle relaxant effect.
 Overall, anesthesia requirements are decreased.
 Because of bradycardia, presser administration will probably not be helpful
unless cardiac output also increases

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 Cont.
Maintenance
 Inhalation of nitrous oxide plus supplementation if necessary with a short-
acting opioid, benzodiazepine
 A volatile agent may not be recommended for symptomatic patient for fear
of exaggerated cardiac depression
 Vasodilatation induced by any drug in the presence of hypovolemia or
attenuated baroreflex could result in abrupt decrease in blood pressure

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 Cont.
Postoperative :
 Hypothyroidism does not alter mean alveolar concentration (MAC)
 Recovery from general anesthesia may be delayed in hypothyroid patients
by hypothermia, respiratory depression, or slowed drug biotransformation
 These patients often require prolonged mechanical ventilation
 Patients should remain intubated until awake and normothermic.
 Because hypothyroidism increases vulnerability to respiratory depression, a
non opioid such as ketorolac would be a good choice for relief of
postoperative pain
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 Anesthesia
and
parathyroid disease

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 Parathyroid Glands
• Four glands behind thyroid gland
• Produce parathormone
– Released based on plasma calcium concentration
– Promote movement of calcium across three
interfaces
• GI tract
• Renal tubules
• Bone

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 Hyperparathyroidism
 Hypercalcemia: Serum calcium > 5.5 mEq/L,

– If Serum calcium > 8 mEq/L, cardiac conduction disturbances

 Sx’s: “Bones, Stones, Groans, Moans”
 Bones – skeletal muscle weakness, osteopenia, fractures
 Stones – renal stones
 Groans – abdominal pain, peptic ulcers, pancreatitis, vomiting
 Moans – sedation, memory loss, personality changes, hallucinations
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 Treatment of Hyperparathyroidism
• Medical
– Saline infusion – 150 mL/hr for intravascular volume depletion
– Loop diuretics – Furosemide 40-80mg iv q2-4hrs -> goal UOP
3-5L/day
– Bisphosphonates for life-threatening hypercalcemia – inhibit
osteoclastic activity
• Surgical
– Surgical removal is definitive treatment
– Serum calcium normal in 3-5 days

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 Anesthetic Management for Hyperparathyroidism

• Hypercalcemia – maintenance of hydration and UOP

• Avoid ketamine if personality changes already
• Unpredictable response to NMBD – initially decrease dose
• Careful positioning – given osteoporosis
• Theoretically, don’t hyperventilate, Respiratory alkalosis lowers serum
K+, leaves actions of calcium unopposed at cardiac myocytes

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 Hypoparathyroidism
• Serum calcium < 4.5 mEq/L
• Acute hypocalcemia
– Perioral paresthesias
– Restlessness
– Neuromuscular irritability
• Chvostek’s sign, Trousseau’s sign
• Inspiratory stridor – neuromuscular irritability of intrinsic laryngeal
musculature
• Chronic hypocalcemia
– Fatigue, personality changes
– Skeletal muscle cramps
– QT prolongation
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 Treatment of Hypoparathyroidism
Tx of Hypocalcemia Anesthetic considerations

• Whole blood containing citrate won’t decrease

• Infusion of calcium until
serum calcium concentrations, because rapidly
neuromuscular irritability
mobilized from stores
disappears • Ionized calcium can decrease with rapid
infusions of blood and when citrate
elimination impaired – hypothermia, cirrhosis,
renal dysfunction

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 Reference
 Clinical anesthesia 8th ed, Paul G. Barash
 Clinical anesthesia 6th ed, G. Edward Morgan
 Miller’s anesthesia 8th ed, Ronald D. Miller
 Anesthesia and co-existing disease 5th ed, Robert K. Stooliting
 Morgan, Clinical Anesthesiology 6th edition

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