Prof. A. K. Sethi’s EORCAPS 2007
Sethi’s EORCAPS 2007
Thyroid Swelling with
Hypothyroidism
Dr Raktima Anand
Prof. A. K. Sethi’s EORCAPS 2007
What is hypothyroidism?
It is an underactivity of the thyroid gland with
decreased synthesis and secretion of T4
May be characterised by a variety of
symptoms due to insufficient organ function.
Prof. A. K. Sethi’s EORCAPS 2007
T3 & T4 circulate bound to plasma proteins
but free T3 & T4 are metabolically active.
T3 feedbacks on pituitary to inhibit prodn of
TSH
Some circ. T4 is metabolised to inactive
product reverse T3
Both T3 & rT3 are rapidly cleared from
serum
Thyroid hormone activity begins with
binding of T3 to receptors on cell nuclei
which is reqd for normal cellular function.
Prof. A. K.
Case report
A 35 yr lady for lap cholecystectomy
presents with h/o somnolence, reduced
appetite, weight gain and easy fatiguability.
On examn, pulse rate is 58/min, BP is
150/100 mmHg. She has thick coarse skin
and weighs 75 kg. Her MP grade is III.
What is your diagnosis? How will
you prepare her for surgery?
Prof. A. K. Sethi’s EORCAPS 2007
Describe the normal regulation
and activity of thyroid hormone.
TRH stimulates synthesis and release of
TSH from the pituitary
Circulating TSH stimulates thyroid gland to
produce and secrete T4 (about 80%) and
smaller amounts of T3 (about 20%)
Remainder of T3 is produced in
extrathyroideal tissues ( liver / kidney )
Prof. A. K. Sethi’s EORCAPS 2007
How is thyroid hormone synthesised
and released?
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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Body has 5000µg iodine(90% in

Synthesis and release thyroid)
Iodine ---> iodide ---> (TSH) iodide
Iodine oxidation (peroxidase) trapping*---> (peroxidase) iodine--->
Organic binding (MIT,DIT) Coupling to tyrosine residues ** --->
Oxidative coupling (T3, T4) MIT, DIT, T3, T4 ---> (proteases)
Storage release of hormones and iodine
Release
Metabolism * inhibited by thiocyanate, perchlorate
** inhibited by thioureas

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

How are thyroid hormones regulated? Effects of thyroid hormones?

By a negative Essential for normal metabolism of all cells

feedback loop Required for synthesis of many proteins
eg. beta receptors (absence leads to lack of
responsiveness to vasopressors)
Induces transcription of cellular enzymes
Calorigenic- incresed O2 consumption & CO2
prodn, BMR, basal body temp.

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Modifies energy use - glucose mobilisation,

insulin secretion, FFA mobilisation
CVS; Î HR, Î CO, increased BP, vasodilatn,
Î tissue perfusion, enhanced effects of What is
catecholamines
Primary hypothyroidism?
CNS; irritability, insomnia, agitation
Genitourinary Secondary hypothyroidism?
Growth and dev. Tertiary hypothyroidism?
Vitamin synth.

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

What is the etiology of hypothyroidism?

Primary; Thyroid gland dysfunction
A-I thyroid disease / Hashimotos
Surgical resection
Radioactive thyroid ablation
Irradiation of neck
Thyroid hormone deficiency
Antithyroid drugs, amiodarone, lithium
Iodine excess / deficiency
Secondary ; pituitary disease
Tertiary; hypothalamic disease

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

What are the features of thyroid

What is “euthyroid sick syndrome”? hormone deficiency?

Seen in critically ill patients who have low
thyroid hormone levels but this may be a
physiological response to reduced oxygen
consumption and catabolism during stress
In contrast to hypothyroidism, TSH level is
low to slightly high
Generalised redn in metabolic activity
CNS; dulling
Respiratory; fall in MBC, diffusion
capacity, impaired vent responses to
hypoxia & hypercarbia, sleep apnoea,
pleural effusion, weak resp ms
CVS ; bradycardia, high SVR, pericardial
effusion, angina (rare; more after hormone
repl), cardiomegaly

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Anaemia, Signs and symptons of hypothyroidism?

Coagulopathy,
Hypothermia Depressed mental acuity/ somnolence/ lethargy
Impaired free water clearance-hyponatremia Hoarseness of voice
hypoglycaemia Cold intolerance, dry skin, brittle hair
Weight gain despite decrease in appetite
Decreased GIT motility Menorrhagia
Slow movements, skel. ms weakness, Arthralgia, carpal tunnel synd.
delayed deep tendon reflexes Sleep apnoea
‘hung up’ reflexes
Periorbital / facial edema
constipation

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Findings on clinical examination ? Hypotension

Sinus bradycardia
Hypothermia (core temp. <35°) Low output cardiac failure,
Dry skin with thickened, doughy cardiomyopathy, pericardial effusion
appearance Hypoventilation (slow RR, shallow
Facial and generalised puffiness breaths)
(periorbital oedema, large tongue) Disorders of muscle function-paralytic
Depressed mental status ( lethargy, ileus, urinary retention, atonic bowel
coma)

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

How do you establish the diagnosis? Likely associated lab. anomalies?

hyponatremia
Clinical suspicion
hypoglycaemia
Thyroid function Tests
hypercholesterolaemia
Other lab. Tests - CBC, S.elect., urine, ABG,
CXR, ECG normocytic normochromic anaemia
ABG - hypoxaemia, hypercarbia
S.Cortisol - to evaluate for concomitant adrenal
insufficiency

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

THYROID FUNCTION TESTS

Others
Hormone Assay
CXR pleural/ pericardial effusion
T4 ; 4-11 µg %
ECG- sinus bradycardia, small voltage
QRS, prolonged QT interval, isoelectric T T3; 90 - 160 ng %
wave changes, SVT Free T4 ; 1-2 ng %
Radiology of upper airway (if goitre) –X Free T3 ; 0.2 - 0.4 ng%
ray ST neck, USG, CT scan
All are good indicators of hyperthyroidism
but poor indicators of hypothyroidism

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

What is RAIU?
normal 5-30% What is RT3U ?
Used ; to confirm hyperthyroidism
part of TRH stimn test normal 25-35%
part of thyroid suppression test Quantifies % satn of thyroglobulin
Not a good indicator of hypothyroidism Uptake inversely proportional to conc. of
Urinary RAI excretion ? unoccupied sites on thyroglobulin
normal 60-80% Î in hyperthyroidism
< 35% suggests hyperthyroidism Decreased in hypothyroidism
Î in hypothyroidism

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Factors affecting TBG

Tests independent of TBG
Increased levels Decreased levels

Pregnancy Androgens
FTI ( normal 55-145 )

Neonates Steroids
increased in hyperthyroidism
Oral contraceptives Cirrhosis decreased in hypothyroidism
Viral hepatitis Nephrotic synd.
CAH Severe illness
Ac intermittent porphyria phenytoin

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

TSH levels TSH stimulation test

Increases in hypothyroidism of pituitary
origin
normal < 5 µU/ml No increase in primary hypothyroidism

Increased in hypothyroidism and is the best TRH stimulation test

indicator
Supranormal response in primary
Decreased/ negligible in secondary / tertiary hypothyroidism
hypothyroidism Subnormal resonse ; pituitary
hypothyroidism and thyrotoxicosis

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

To summarise…………… Radioimaging ;
T4 T3 TSH RT3U
Thyroid scan ;
Hyperthyroidism increase increase fall increase
- delineates active thyroid tissue
Hypothyroidism fall fall increase fall
- diagnoses retrosternal extension
Pit. Hypo fall fall fall fall

pregnancy increase fall normal normal

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Other tests ; Other Appropriate tests?

BMR (after 12 hrs fasting)

USG Other lab tests
FNAC ECG
Venography CXR
Ab titres- anti T3 Radiology of airway( IF large goitre) X ray
anti T4 STN –AP / lat, Ba swallow
thyroid antimicrosomal CT scan
antithyroglobulin I/L

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Preoperative preparation? Thyroid hormone supplementation

Assess the thyroid status Levo thyroxine

Any soft tisue compression? 1.6- 1.8 µg/kg/day (healthy, no CAD, <60 yrs)
Airway, SVC, Oeso, RLN, symp.trunk 50 µg/day (elderly, CAD)
Rule out IHD , pc effusion, pleural effusion, 25 µg/ day (longstanding, severe hypothyroid)
ascites
Rule out adrenal involvement L tri iodothyronine
Evaluate extent of involvement of other Thyroid extract
organ systems

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Hormone replacement essential;

Subclinical hypothyroidism ( TSH 5- Severe hypothyroidism

15µ/ml) ; no need to postpone surgery Myxedema coma
Pregnancy with hypothyroidism
Moderate cases – little concern

Severe myxedema must postpone if possible

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

IHD and hormone replacement ;

In pts with symptomatic CAD may ppt mc If hypothyroid patient requires

ischaemia urgent surgery?
In unstable pts / severe IHD- first consider Synthetic T3 50-100 microgm slow iv under
coronary revascularisation and then start ECG guidance and then 25 microgm 8 hrly
thyroxine therapy Steroids
? Amrinone (inovasodilator) may improve
mc contractility

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Premedication; Intraoperative monitoring

No sedatives ECG
Consider aspiration prophylaxis BP- NIBP/ IBP
Temperature
SpO2
EtCO2
NMJ monitoring

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Prevent hypocarbia/hypercarbia- control

Main intraoperative considerations? ventilation
Prevent hypoglycaemia, electrolyte
Restore intravascular volume before induction imbalance - hyponatremia
Invasive monitoring is desirable Maintain temp.
Preoxygenate Poor circuln; poor barorec reflexes
Difficult airway- obesity, large tongue, heavy Keep ready sympathetic/ vagolytic drugs
jaw Prone to IHD- exacerbated by thyroid
Minimise all anaesthesia drugs replacement
Myxedema coma

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Drug effects Drug effects (ctd)

More sensitive to all anaesthetic drugs No decrease in MAC of inhalation agents

More sensitive to hypotensive effects of ( clinical impression d/t decreased CO,
anaesth. agents hypothermia)
(may be due to decreased CO, blunted Preferred ms relaxant ? panc (vagolytic)
baroreceptor reflexes, decreased
intravascular volume, decreased hepatic
met. &renal excretion)
Ketamine/ etomidate proposed as drugs of
choice for induction

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Postoperative problems?
Role of regional anaesthesia ;
Perioperative hypothermia
Restore intravascular volume ( Patients may CVS problems
have intense vasoconstriction) GIT hypomotility
Rule out neuropathy and coagulopathy Prolonged recovery from anaesthesia
before regional anaesthesia Neurpsychiatric disturbances
Slow drug metabolism
May need postoperative ventilatory support
(COAD, obese, myxedema)
May develop myxedema coma

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

THE CASE What is myxedema coma?

62 yr lady with # left femur neck.Vitals were rectal
temp 36°, HR 62/min, BP 95/62 mm Hg, RR
10/min.Underwent surgery under GA and A life threatening complication of severe
developed sinus bradycardia with PVC’s. She
hypothyroidism characterised by a
remained intubated and was taken to ICU for
postoperative care. Over the next 24 hrs she decreased level of consciousness, even
remained bradycardic and unconscious with GCS coma
6. Attempts to wean off ventilator were
unsuccessful due to CO2 retention. Pt required
warming to keep her core temp. above 36°C. TFT
revealed increased TSH and very low T3 levels.

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Management of hypothyroid coma. Thyroid hormone replacement;

Oral absorption unreliable- use iv route

1. Thyroid hormone replacement
Can use combination of T3 and T4 for 1-2
2. General supportive measures days
3. Cardiovascular supportive measures T3 20 µg iv & 10 µg 8 hrly
T4 200 µg iv & 100 µg every 24 hrs
Previously used T4 alone ; 200-500 µg iv
every 24 hrs
Monitor T3 & T4 levels after 5 days and
adjust dose

Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

General supportive measures; Cardiovascular supportive measures;

IVF to restore intravascular volume Inotropes after restoring intravascular vol

Passive warming (never active) ( Hypotension is poorly responsive to
Mechanical ventilation vasopressors until hormone replacement)
Treat any seizures Monitor for arrythmias
Use sedatives cautiously Monitor for myocardial ischaemia – may be
Hydrocortisone 100 mg 8 hrly til evaln of exacerbated by thyroid replacement
hypothalmo-pit-adr axis

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 Prof. A. K. Sethi’s EORCAPS 2007 Prof. A. K. Sethi’s EORCAPS 2007

Myxedema coma
hypothyroxinaemia Iv thyroxine
hypothermia Blankets(no active
warming)
hypoventilation Mech ventiln
hypotension
hyponatremia
IVF
Cautious fluids
THANK YOU!
hypoglycaemia glucose
hypocortisolaemia Glucocorticoids

Treat precipitating event

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