Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

Authors: William R Furman, MD, Amy C Robertson, MD

Section Editor: Stephanie B Jones, MD
Deputy Editor: Marianna Crowley, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2017. | This topic last updated: Jul 17, 2017.

INTRODUCTION — Thyroid disease and thyroid surgery present specific challenges for anesthesiologists.

This topic reviews the preanesthetic evaluation, intraoperative management, and immediate postoperative care
of patients with thyroid disease, including those having thyroid surgery. Preoperative medical management of
patients with thyroid disease, perioperative surgical management of patients undergoing thyroid surgery, and
urgent management of severe and life-threatening overt thyroid storm are reviewed separately. (See
"Nonthyroid surgery in the patient with thyroid disease" and "Surgical management of hyperthyroidism" and
"Initial thyroidectomy" and "Thyroid storm".)

ANESTHETIC CONCERNS — Patients with either hyper- or hypothyroidism have associated physiologic
changes that influence anesthetic care. Mechanical thyroid-related airway problems are generally limited to
patients with large substernal or invasive goiters or thyroid tumors, or postoperative surgical complications that
impact the airway.

Hyperthyroidism — As the degree of hyperthyroidism increases, clinical manifestations are more prominent
and have a greater potential impact on anesthetic care. These physiologic changes resolve with treatment, as
the patient becomes euthyroid. (See "Overview of the clinical manifestations of hyperthyroidism in adults".)

● Cardiovascular changes may lead to perioperative hemodynamic instability. Hyperthyroid patients have
increased heart rate, circulating blood volume, cardiac contractility, and myocardial oxygen consumption,
as well as enhanced diastolic relaxation and reduced systemic vascular resistance. Patients are also prone
to arrhythmias (sinus tachycardia and atrial fibrillation), coronary spasm and ischemia, and may have
cardiomyopathy in the late stages [1-9]. (See "Cardiovascular effects of hyperthyroidism".)

● Respiratory muscle weakness may mandate postoperative mechanical ventilatory support after general
anesthesia [10,11]. (See "Respiratory function in thyroid disease".)

● Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of

thyrotoxicosis [12]. It has been reported during surgery and in the first 18 hours after surgery in
hyperthyroid patients. (See "Nonthyroid surgery in the patient with thyroid disease", section on 'Thyroid
storm'.)

Hypothyroidism — Severe hypothyroidism has a greater impact on anesthetic care than mild or well-treated
disease. The physiologic changes of hypothyroidism do resolve with treatment, as the patient becomes
euthyroid. (See "Clinical manifestations of hypothyroidism".)

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…ource=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 1 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

● Cardiovascular abnormalities may lead to perioperative hemodynamic instability or myocardial ischemia.

Clinically hypothyroid patients may have bradycardia, diminished response to adrenergic agents, diastolic
dysfunction, increased systemic vascular resistance, and impaired venous return [1,2,13-15]. Patients with
hypothyroidism, even subclinical disease, are at increased risk for ischemic heart disease [16,17].

● Rapid detection and treatment of hypotension (or hypertension) is facilitated by an intra-arterial catheter for
continuous arterial blood pressure monitoring [18,19]. Hypothyroid patients may have a diminished
response to alpha and beta adrenergic agents [2]. Hypotension can be treated with alpha-agonists and
direct or indirect sympathomimetics (eg, phenylephrine or ephedrine), although larger doses may be
required. (See "Cardiovascular effects of hypothyroidism".)

● Hypothyroid patients may have upper airway obstruction due to sleep apnea and increased tongue size
[20,21]. Thus, the airway should be secured during surgery.

● Respiratory effects of the hypothyroid state include impaired ventilatory drive and respiratory muscle
weakness, which can lead to alveolar hypoventilation [22-24]. Also, hypothyroid patients are extremely
sensitive to the effects of drugs that depress respiratory drive, such as opioids and sedatives [18,19,25].
Thus, ventilation should be controlled during surgery.

Patients with severe clinical hypothyroidism (especially those with myxedema coma) are at risk for delayed
emergence and may require prolonged ventilatory support. (See "Respiratory function in thyroid disease".)

● Metabolic abnormalities may include hyponatremia due to a reduction in free water clearance, reversible
increases in serum creatinine, and reduced clearance of hypnotic and opioid medications [20]. Other
concerns include hypoglycemia, anemia, and hypothermia.

Airway problems — Anatomic airway problems may be caused by an enlarged thyroid gland (goiter) or by
complications of thyroid surgery.

● Tracheal deviation or narrowing may be caused by compression from enlargement of the thyroid gland. If
the enlarged gland is symptomatic, invasive, or substernal, the approach to induction and intubation may
need to be altered.

● Substernal goiters are present in 2 to 19 percent of patients having thyroidectomy [26]. This may change
the surgical approach. Substernal goiters are located in the anterior mediastinum in 75 to 90 percent of
cases [27]. An anterior mediastinal mass must be thoroughly evaluated preoperatively, since induction of
anesthesia and positive pressure ventilation may result in obstruction of major airways or major
cardiovascular structures. (See "Clinical presentation and evaluation of goiter in adults", section on 'Goiter
with obstructive symptoms or suspected substernal goiter' and "Treatment of obstructive or substernal
goiter" and "Anesthesia for patients with an anterior mediastinal mass".)

● Surgical airway complications may manifest in the postoperative period as critical emergencies
necessitating emergent reintubation.

• Injury to the nerves innervating the larynx may result in the patient’s inability to maintain the airway
after extubation. (See "Respiratory problems in the post-anesthesia care unit (PACU)", section on

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 2 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

'Vocal cord paralysis'.)

• Neck hematomas caused by bleeding from the surgical site may cause airway compression requiring
urgent surgical decompression. (See "Respiratory problems in the post-anesthesia care unit (PACU)",
section on 'Cervical hematoma'.)

• Rarely, long-standing tracheomalacia may cause collapse of the tracheal wall with airway obstruction.
(See "Initial thyroidectomy", section on 'Complications'.)

PREOPERATIVE EVALUATION

Thyroid function — When diagnosis and medical control of thyroid disease have occurred prior to elective
surgery, the preanesthetic evaluation need only confirm that the patient is euthyroid. Patients taking a stable
dose of thyroid medication, with documented euthyroid status within the past three to six months, do not need
additional testing prior to surgery. (See "Nonthyroid surgery in the patient with thyroid disease", section on 'Is
preoperative measurement of TSH necessary?'.)

In contrast, elective surgery should be delayed in patients with recently diagnosed thyroid disease, and in those
who remain hyperthyroid or hypothyroid, until treatment results in a documented euthyroid state. If urgent or
emergent surgery is required, patients with severe hypothyroidism or hyperthyroidism should receive treatment
of their disease prior to surgery, as time allows, in order to minimize complications. (See "Nonthyroid surgery in
the patient with thyroid disease", section on 'Hypothyroidism' and "Nonthyroid surgery in the patient with thyroid
disease", section on 'Hyperthyroidism'.)

Severe hypothyroidism includes patients with [28,29]:

● Myxedema coma

● Severe clinical symptoms of chronic hypothyroidism such as altered mental status, pericardial effusion, or
heart failure.

● Very low levels of total thyroxine (eg, less than 1.0 mcg/dL) or free thyroxine (eg, less than 0.5 ng/dL)

In overt hyperthyroidism, both serum free T4 and T3 are usually elevated and serum TSH is undetectable.
Severe hyperthyroidism includes patients with [30,31]:

● Thyrotoxicosis or thyroid storm

● Severe clinical symptoms of tachycardia (>140 beats per minute), arrhythmias, congestive heart failure,
hyperpyrexia, agitation, psychosis, or coma.

Details regarding urgent treatment regimens in these situations are reviewed elsewhere. (See "Nonthyroid
surgery in the patient with thyroid disease", section on 'Preoperative preparation for urgent surgery' and
"Nonthyroid surgery in the patient with thyroid disease", section on 'Moderate (overt) hypothyroidism' and
"Nonthyroid surgery in the patient with thyroid disease", section on 'Severe hypothyroidism'.)

Airway evaluation — While an enlarged thyroid (goiter) may cause airway problems due to invasion of airway

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 3 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

structures, extension into the mediastinum, and compression of the trachea, we do not routinely order
additional imaging studies to assess the airway in patients with thyroid disease or a goiter [32-34]. In a
prospective study of thyroidectomy patients, difficult endotracheal intubation was predicted most often by the
usual anatomic predictive factors (table 1), rather than the size of the goiter or the presence of tracheal
compression [32]. In fact, the presence of a large benign goiter seldom changes airway management plans
[35].

Studies that may already be available as part of the surgical evaluation for thyroidectomy include laryngoscopy
and ultrasound of the thyroid gland. If respiratory symptoms are present or substernal goiter is suspected,
computed tomography or magnetic resonance imaging is often obtained to assess the size of a goiter, its
caudal extent, and the extent of tracheal compression, as well as pinpointing the location of the mass (eg,
anterior or posterior mediastinum) [34,36]. Other studies may have been ordered to evaluate the full extent of
the mass and its effects upon surrounding structures. (See "Clinical presentation and evaluation of goiter in
adults", section on 'Goiter with obstructive symptoms or suspected substernal goiter'.)

All available studies should be reviewed by the anesthesiologist, with particular attention to the following clinical
entities:

● Cancerous goiter – The presence of a cancerous goiter is an independent risk factor for difficult
intubation, possibly because tracheal invasion and tissue infiltration with associated fibrosis may reduce
the mobility of laryngeal structures and impede the view of the glottic opening with laryngoscopy [32,33].

● Obstructive or substernal goiter – Extension of the thyroid below the sternal notch (ie, substernal goiter)
results in respiratory symptoms in 90 percent of patients and dysphagia in one-third [34]. Respiratory
symptoms, including hoarseness, dyspnea, wheezing, obstructive sleep apnea, or cough, may be caused
by tracheal compression or nerve involvement. (See "Clinical presentation and evaluation of goiter in
adults", section on 'Obstructive symptoms'.)

ANESTHETIC MANAGEMENT

Choice of anesthetic technique — Clinical outcomes after thyroid surgery do not differ in patients who receive
general anesthesia compared to local or regional anesthesia [37-39].

General anesthesia — We prefer general anesthesia for thyroid surgery, unless local or regional anesthesia
is requested by the patient and/or the surgeon. Advantages of general anesthesia include lack of awareness,
secure control of the airway, and an immobile surgical field. Also, use of general anesthesia at the outset avoids
the need for urgent conversion from a local/regional to a general anesthetic technique. (See 'Intraoperative
anesthetic management' below.)

Local or regional anesthesia — An alternative to general anesthesia for thyroidectomy is infiltration of local
anesthetic or use of a cervical plexus block (superficial or deep), with monitored anesthesia care as part of the
technique. Adequate analgesia should desensitize the platysma, strap muscles, and thyroid capsule. Typically,
this requires multiple injections of local anesthetic along the posterior border of the sternocleidomastoid muscle
(figure 1).

Advantages of local/regional anesthesia include avoidance of endotracheal intubation, a shorter recovery

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 4 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

period with less nausea, and possibly lower cost [37,38,40]. Complications of cervical plexus block for
thyroidectomy include injection into the thyroid gland with resultant hematoma, infiltration of the vagus nerve
leading to temporary paresis of the ipsilateral recurrent laryngeal nerve, and intravascular injection [40,41].

Surgical contraindications to a local/regional anesthetic technique include retroesophageal or retrotracheal

goiter, previous cervical surgery, known or suspected locally invasive cancer, and planned concomitant cervical
lymphadenectomy [40,41]. Language or cognitive difficulties that create a communication barrier, anticipated
difficult intubation, obesity, sleep apnea, inability to lie flat, and claustrophobia are possible contraindications
[41]. Patient preference for general anesthesia is an additional contraindication. Furthermore, 2 to 12 percent of
patients undergoing thyroidectomy with local/regional anesthesia require conversion to general anesthesia
because of anxiety, inadequate anesthesia, surgical difficulty, or airway problems [39-41]. Concern regarding
the need for an urgent and possibly difficult intraoperative intubation dissuades many anesthesiologists from
offering regional anesthesia to thyroidectomy patients.

Cervical plexus blocks are not indicated solely for postoperative analgesia after thyroidectomy, as the addition
of bilateral superficial cervical plexus blocks to general anesthesia does not result in clinically significant
improvement in analgesia [42].

Intraoperative anesthetic management

Monitoring — Patients with well-controlled thyroid disease need only standard monitors, including
electrocardiography, noninvasive blood pressure monitoring, pulse oximetry, and capnography. Patients who
remain clinically hyperthyroid at the time of surgery may benefit from invasive monitoring of blood pressure with
an intra-arterial catheter, in order to immediately detect and treat hyper- or hypotension.

The use of intraoperative neuromonitoring to detect injury to the recurrent laryngeal nerve is discussed
separately [43]. (See "Initial thyroidectomy", section on 'Intraoperative nerve monitoring'.)

Induction and intubation — During induction of anesthesia, the airway may be managed with standard
intubation techniques in most patients with thyroid disease. However, it is a reasonable precaution to have
smaller than usual endotracheal tubes available. (See 'Airway evaluation' above.)

Goiters or other thyroid tumors usually do not cause difficulty with intubation, unless the patient is symptomatic
due to tracheal compression or tissue invasion by the tumor. However, goiters that are substernal in the anterior
mediastinum may cause obstruction of major airways or cardiovascular structures. Thus, final plans for
induction of anesthesia and airway management are based on thorough evaluation of the mass with computed
tomography or magnetic resonance imaging. (See "Anesthesia for patients with an anterior mediastinal mass"
and 'Airway evaluation' above.)

Patients with stridor due to severe tracheal compression should be intubated awake to limit the risk of complete
airway obstruction when spontaneous ventilation ceases. The surgical team should be prepared and ready to
perform an emergent tracheotomy or rigid bronchoscopy for patients with airway compromise [34].

When recurrent laryngeal nerve monitoring is used, neuromuscular block must be avoided during surgical
dissection. Therefore, in this setting, a short-acting neuromuscular blocking agent (NMBA), or no NMBA, should
be used for intubation. Succinylcholine (0.6 to 1.5 mg/kg) can be administered to facilitate intubation, as

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 5 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

recovery from paralysis will be complete within several minutes. When succinylcholine cannot be used (patients
with burns, denervating injuries, neuromuscular disease) techniques that do not require NMBAs should be
considered (eg, remifentanil 2.5 to 4 mcg/kg IV with propofol 2 mg/kg and ephedrine 10 to 15 mg IV). (See
"Airway management for induction of general anesthesia", section on 'Choice of medications for induction and
intubation'.)

Maintenance of anesthesia — When recurrent laryngeal nerve monitoring is used, NMBAs should be
avoided during maintenance of anesthesia.

We use standard oxygen supplementation in these patients. While one study suggested a beneficial effect of a
high fraction of inspired oxygen (80 percent during and after surgery) on certain complication rates, these data
are preliminary and require confirmation [44].

Hyperthyroid patients — Anesthesia should be maintained at a depth that is adequate to avoid

hyperdynamic responses to surgical stimulation (eg, tachycardia and hypertension). Patients with
hyperthyroidism may have increased anesthetic requirements because of increased sympathetic
responsiveness [45].

For the same reason, administration of medications with sympathetic or sympathomimetic effects (eg,
epinephrine, ephedrine, ketamine, or atropine) may result in exaggerated responses; thus, these drugs are
avoided if possible. Hypotension should be treated with direct-acting vasoconstrictors (eg, phenylephrine),
rather than medications that increase catecholamine release [46].

Hyperthyroidism does not increase minimum alveolar concentration (MAC) requirement or the cerebral
metabolic rate of oxygen consumption (CMRO2) [45].

Hypothyroid patients — Hypothyroid patients are sensitive to the effects of drugs that depress
respiratory drive, such as opioids and sedatives [18,19,25].

Hypothyroid patients usually have a diminished response to alpha- and beta-adrenergic agents [2].

There is no evidence that these patients have reduced MAC requirements [47,48].

Emergence and extubation — Patients with thyroid disease, either hyperthyroidism or hypothyroidism, are
carefully assessed for readiness for extubation after general anesthesia. Postoperative mechanical ventilatory
support may be necessary due to respiratory muscle weakness. Severely hypothyroid patients may also have
impaired ventilatory drive. (See "Respiratory function in thyroid disease".)

Severe hypertension or coughing during emergence and extubation may induce bleeding from the surgical site
with consequent airway compromise requiring reintubation and emergent surgical decompression. Strategies to
minimize coughing include extubation under deep anesthesia or administration of remifentanil,
dexmedetomidine, or lidocaine during emergence [49-51]. The choice of technique and drugs is determined by
patient risk factors for coughing (eg, smoking status), as well as the preferences of the anesthesiologist.

Immediately after extubation, airway compromise may develop due to recurrent laryngeal nerve injury, causing
vocal cord dysfunction; tracheomalacia, causing tracheal collapse in patients with long-standing tracheal

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 6 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

compression; or expansion of a cervical wound hematoma, causing new tracheal compression. Immediate
reintubation may be necessary. (See 'Airway complications' below and "Initial thyroidectomy", section on
'Hematoma' and "Initial thyroidectomy", section on 'Nerve injury/vocal cord paresis or paralysis'.)

POSTOPERATIVE COMPLICATIONS

Airway complications

Nerve injury — When there is suspicion of injury to the recurrent laryngeal nerve, extubation should be
performed with plans to immediately reintubate if necessary.

Injury to the nerve may result from trauma due to direct pressure, ligation, or transection [52]. (See "Initial
thyroidectomy", section on 'Nerve injury/vocal cord paresis or paralysis'.) This may be recognized by surgical
observation or monitoring of intraoperative vocal cord function. In the past, it was common practice to attempt
to perform a direct laryngoscopy after extubation in order to confirm that both vocal cords moved normally.
However, this practice does not predict postoperative vocal cord dysfunction and is no longer recommended
[53,54].

When recurrent laryngeal nerve injury occurs, the involved vocal cord assumes a median or paramedian
position, causing hoarseness if trauma is unilateral, but no airway obstruction. However, bilateral involvement is
more serious, since the patient usually experiences stridor and may have complete airway obstruction.
Immediate reintubation, and occasionally tracheostomy, may be necessary.

Injury to the superior laryngeal nerve (in contrast to the recurrent laryngeal nerve) has no effect on
postoperative airway status. Rather, it manifests as voice fatigue and changes in voice quality [55].

Cervical hematoma — Postoperative cervical hematoma requiring emergent surgical evacuation is a rare
but potentially serious complication of thyroidectomy. Bleeding and hematoma formation may cause venous
congestion of airway structures, and airway compromise may develop rapidly due to compression of the
trachea or laryngeal edema as the hematoma expands. When surgical bleeding causes airway compromise,
emergent re-operation may be required to evacuate the hematoma. Head-up position to lower venous
pressures, nebulized epinephrine, and systemic steroids may be useful temporizing strategies; however,
definitive treatment should not be delayed [56,57].

If time permits, the patient should be returned to the operating room; however, rapidly developing airway
compromise may require bedside evacuation of the hematoma. Distortion of airway anatomy can occur, so the
safest method for intubation may be an awake intubation (table 2).

Tracheomalacia — Longstanding tracheal compression by a goiter may lead to tracheomalacia [27].

Although rare, prolonged compression may cause atrophy and erosion of cartilaginous tracheal rings. After
thyroid resection, the tracheal wall may collapse in an anteroposterior direction, leading to airway obstruction. In
our experience, the absence of airflow around the endotracheal tube after deflating the cuff (ie, absence of a
“cuff leak”) may identify those patients at risk for post-extubation airway compromise [58].

Other complications

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 7 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

Thyroid storm — If clinical signs of thyroid storm (hyperthermia and tachycardia) develop during surgery,
therapeutic measures to treat hyperthyroidism (eg, beta-blocking agents and thioamides) are immediately
initiated. Other supportive measures include aggressive treatment of hyperpyrexia with cooling blankets and
acetaminophen and administration of a glucocorticoid (eg, hydrocortisone). Ongoing support and monitoring in
the critical care setting is strongly recommended since the mortality rate is substantial in patients with thyroid
storm [59]. (See "Thyroid storm", section on 'Treatment' and "Nonthyroid surgery in the patient with thyroid
disease", section on 'Thyroid storm'.)

Hypocalcemia — Following total thyroidectomy, there is a risk that removal of parathyroid tissue will result
in severe hypocalcemia. Thus, patients should be specifically monitored for hypocalcemia in the postoperative
period.

Complications of parathyroidectomy — Complications of parathyroidectomy, including hypocalcemia, are

discussed separately. (See "Parathyroid exploration for primary hyperparathyroidism", section on
'Complications'.)

SUMMARY AND RECOMMENDATIONS

● In most patients, the preanesthetic evaluation need only confirm that the patient is euthyroid. Elective
surgery is delayed in patients with recently diagnosed thyroid disease and those who are clinically
hyperthyroid or hypothyroid. Patients with severe hypothyroidism or hyperthyroidism who need urgent or
emergent surgery should receive immediate treatment prior to surgery. (See 'Preoperative evaluation'
above.)

● We prefer general anesthesia for thyroid surgery. Advantages of general anesthesia include lack of
awareness, secure control of the airway, and an immobile surgical field, as well as avoidance of the need
for urgent conversion from local/regional to general anesthesia. However, clinical outcomes do not differ in
patients who receive local or regional versus general anesthesia. (See 'Choice of anesthetic technique'
above.)

● An enlarged thyroid (goiter) may cause airway problems if symptomatic compression of the trachea,
extension into the mediastinum, or invasion into airway structures has occurred. These patients may need
additional testing to evaluate airway anatomy. (See 'Airway evaluation' above.)

● A smaller than usual endotracheal tube size may be required in patients with potential airway problems.
Patients with stridor due to tracheal compression are intubated awake, with the surgical team standing by
ready to perform emergent tracheotomy or rigid bronchoscopy. (See 'Induction and intubation' above.)

● After thyroid surgery, post-extubation airway compromise may develop, caused by vocal cord dysfunction
due to recurrent laryngeal nerve injury, tracheal compression due to an expanding wound hematoma, or
tracheomalacia due to long-standing tracheal compression. Immediate reintubation may be necessary, as
well as emergent surgical decompression of any wound hematoma. (See 'Airway complications' above.)

● Other possible postoperative complications requiring immediate treatment include thyroid storm and
severe hypocalcemia. (See 'Other complications' above.)

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 8 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med 2001; 344:501.
2. Deegan RJ, Furman WR. Cardiovascular manifestations of endocrine dysfunction. J Cardiothorac Vasc
Anesth 2011; 25:705.
3. Sawin CT, Geller A, Wolf PA, et al. Low serum thyrotropin concentrations as a risk factor for atrial
fibrillation in older persons. N Engl J Med 1994; 331:1249.
4. Klemperer JD, Ojamaa K, Klein I. Thyroid hormone therapy in cardiovascular disease. Prog Cardiovasc
Dis 1996; 38:329.
5. Das KC, Mukherjee M, Sarkar TK, et al. Erythropoiesis and erythropoietin in hypo- and hyperthyroidism. J
Clin Endocrinol Metab 1975; 40:211.
6. Resnick LM, Laragh JH. PLasma renin activity in syndromes of thyroid hormone excess and deficiency.
Life Sci 1982; 30:585.
7. Feldman T, Borow KM, Sarne DH, et al. Myocardial mechanics in hyperthyroidism: importance of left
ventricular loading conditions, heart rate and contractile state. J Am Coll Cardiol 1986; 7:967.
8. Kahaly GJ, Kampmann C, Mohr-Kahaly S. Cardiovascular hemodynamics and exercise tolerance in
thyroid disease. Thyroid 2002; 12:473.
9. Lee SM, Jung TS, Hahm JR, et al. Thyrotoxicosis with coronary spasm that required coronary artery
bypass surgery. Intern Med 2007; 46:1915.
10. McElvaney GN, Wilcox PG, Fairbarn MS, et al. Respiratory muscle weakness and dyspnea in thyrotoxic
patients. Am Rev Respir Dis 1990; 141:1221.
11. Siafakas NM, Milona I, Salesiotou V, et al. Respiratory muscle strength in hyperthyroidism before and
after treatment. Am Rev Respir Dis 1992; 146:1025.
12. Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord 2003; 4:129.
13. Biondi B. Cardiovascular effects of mild hypothyroidism. Thyroid 2007; 17:625.
14. Virtanen VK, Saha HH, Groundstroem KW, et al. Thyroid hormone substitution therapy rapidly enhances
left-ventricular diastolic function in hypothyroid patients. Cardiology 2001; 96:59.
15. Taddei S, Caraccio N, Virdis A, et al. Impaired endothelium-dependent vasodilatation in subclinical
hypothyroidism: beneficial effect of levothyroxine therapy. J Clin Endocrinol Metab 2003; 88:3731.
16. Cappola AR, Ladenson PW. Hypothyroidism and atherosclerosis. J Clin Endocrinol Metab 2003; 88:2438.
17. Mya MM, Aronow WS. Subclinical hypothyroidism is associated with coronary artery disease in older
persons. J Gerontol A Biol Sci Med Sci 2002; 57:M658.
18. Abbott TR. Anaesthesia in untreated myxoedema. Report of two cases. Br J Anaesth 1967; 39:510.
19. Kim JM, Hackman L. Anesthesia for untreated hypothyroidism: report of three cases. Anesth Analg 1977;
56:299.
20. Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism. Endocrinol Metab

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 9 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

Clin North Am 2003; 32:503.

21. Bahammam SA, Sharif MM, Jammah AA, Bahammam AS. Prevalence of thyroid disease in patients with
obstructive sleep apnea. Respir Med 2011; 105:1755.
22. WILSON WR, BEDELL GN. The pulmonary abnormalities in myxedema. J Clin Invest 1960; 39:42.
23. Zwillich CW, Pierson DJ, Hofeldt FD, et al. Ventilatory control in myxedema and hypothyroidism. N Engl J
Med 1975; 292:662.
24. Siafakas NM, Salesiotou V, Filaditaki V, et al. Respiratory muscle strength in hypothyroidism. Chest 1992;
102:189.
25. Smallridge RC. Metabolic and anatomic thyroid emergencies: a review. Crit Care Med 1992; 20:276.
26. White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J
Surg 2008; 32:1285.
27. Newman E, Shaha AR. Substernal goiter. J Surg Oncol 1995; 60:207.
28. Weinberg AD, Brennan MD, Gorman CA, et al. Outcome of anesthesia and surgery in hypothyroid
patients. Arch Intern Med 1983; 143:893.
29. Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone reduction on
perioperative outcome. Anesth Analg 1997; 85:30.
30. Cooper DS. Hyperthyroidism. Lancet 2003; 362:459.
31. Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management
guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists.
Endocr Pract 2011; 17:456.
32. Bouaggad A, Nejmi SE, Bouderka MA, Abbassi O. Prediction of difficult tracheal intubation in thyroid
surgery. Anesth Analg 2004; 99:603.
33. Bacuzzi A, Dionigi G, Del Bosco A, et al. Anaesthesia for thyroid surgery: perioperative management. Int
J Surg 2008; 6 Suppl 1:S82.
34. Chen AY, Bernet VJ, Carty SE, et al. American Thyroid Association statement on optimal surgical
management of goiter. Thyroid 2014; 24:181.
35. Amathieu R, Smail N, Catineau J, et al. Difficult intubation in thyroid surgery: myth or reality? Anesth
Analg 2006; 103:965.
36. Barker P, Mason RA, Thorpe MH. Computerised axial tomography of the trachea. A useful investigation
when a retrosternal goitre causes symptomatic tracheal compression. Anaesthesia 1991; 46:195.
37. Spanknebel K, Chabot JA, DiGiorgi M, et al. Thyroidectomy using monitored local or conventional general
anesthesia: an analysis of outpatient surgery, outcome and cost in 1,194 consecutive cases. World J Surg
2006; 30:813.
38. Snyder SK, Roberson CR, Cummings CC, Rajab MH. Local Anesthesia With Monitored Anesthesia Care
vs General Anesthesia in Thyroidectomy: A Randomized Study. Arch Surg 2006; 141:167.
39. Specht MC, Romero M, Barden CB, et al. Characterisitcs of patients having thyroid surgery under
regional anesthesia. J Am Coll Surg 2001; 193:367.
40. Spanknebel K, Chabot JA, DiGiorgi M, et al. Thyroidectomy using local anesthesia: a report of 1,025

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 10 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

cases over 16 years. J Am Coll Surg 2005; 201:375.

41. Arora N, Dhar P, Fahey TJ 3rd. Seminars: local and regional anesthesia for thyroid surgery. J Surg Oncol
2006; 94:708.
42. Warschkow R, Tarantino I, Jensen K, et al. Bilateral superficial cervical plexus block in combination with
general anesthesia has a low efficacy in thyroid surgery: a meta-analysis of randomized controlled trials.
Thyroid 2012; 22:44.
43. Angelos P. Recurrent laryngeal nerve monitoring: state of the art, ethical and legal issues. Surg Clin North
Am 2009; 89:1157.
44. Schietroma M, Piccione F, Cecilia EM, et al. How does high-concentration supplemental perioperative
oxygen influence surgical outcomes after thyroid surgery? A prospective, randomized, double-blind,
controlled, monocentric trial. J Am Coll Surg 2015; 220:921.
45. Quasha AL, Eger EI 2nd, Tinker JH. Determination and applications of MAC. Anesthesiology 1980;
53:315.
46. Kohl BA, Schwartz S. How to manage perioperative endocrine insufficiency. Anesthesiol Clin 2010;
28:139.
47. Munson ES, Hoffman JC, DiFazio CA. The effects of acute hypothyroidism and hyperthyroidism on
cyclopropane requirement (MAC) in rats. Anesthesiology 1968; 29:1094.
48. Stoelting RK. Metabolic effects of anesthetics. Int Anesthesiol Clin 1980; 18:53.
49. Lee B, Lee JR, Na S. Targeting smooth emergence: the effect site concentration of remifentanil for
preventing cough during emergence during propofol-remifentanil anaesthesia for thyroid surgery. Br J
Anaesth 2009; 102:775.
50. Park JS, Kim KJ, Lee JH, et al. A Randomized Comparison of Remifentanil Target-Controlled Infusion
Versus Dexmedetomidine Single-Dose Administration: A Better Method for Smooth Recovery From
General Sevoflurane Anesthesia. Am J Ther 2016; 23:e690.
51. Lee JH, Koo BN, Jeong JJ, et al. Differential effects of lidocaine and remifentanil on response to the
tracheal tube during emergence from general anaesthesia. Br J Anaesth 2011; 106:410.
52. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal
nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg 2008; 206:123.
53. Lacoste L, Karayan J, Lehuedé MS, et al. A comparison of direct, indirect, and fiberoptic laryngoscopy to
evaluate vocal cord paralysis after thyroid surgery. Thyroid 1996; 6:17.
54. Malhotra S, Sodhi V. Anaesthesia for thyroid and parathyroid surgery. Contin Educ Anaesth Crit Care
2007; 7:55.
55. Rosato L, Avenia N, Bernante P, et al. Complications of thyroid surgery: analysis of a multicentric study on
14,934 patients operated on in Italy over 5 years. World J Surg 2004; 28:271.
56. Dixon JL, Snyder SK, Lairmore TC, et al. A novel method for the management of post-thyroidectomy or
parathyroidectomy hematoma: a single-institution experience after over 4,000 central neck operations.
World J Surg 2014; 38:1262.
57. Harding J, Sebag F, Sierra M, et al. Thyroid surgery: postoperative hematoma--prevention and treatment.
Langenbecks Arch Surg 2006; 391:169.

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 11 de 12
Anesthesia for patients with thyroid disease - UpToDate 8/11/17 20(21

58. Bajwa SJ, Sehgal V. Anesthesia and thyroid surgery: The never ending challenges. Indian J Endocrinol
Metab 2013; 17:228.
59. Mackin JF, Canary JJ, Pittman CS. Thyroid storm and its management. N Engl J Med 1974; 291:1396.

Topic 91383 Version 16.0

https://www-uptodate-com.ezproxy.sibdi.ucr.ac.cr/contents/anesthes…urce=search_result&search=tyroid%20anesthesia&selectedTitle=1~150 Página 12 de 12