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Official reprint from UpToDate®

www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Anesthesia for patients with thyroid disease and for

patients who undergo thyroid or parathyroid surgery
Authors: William R Furman, MD, Amy C Robertson, MD
Section Editor: Stephanie B Jones, MD
Deputy Editor: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2020. | This topic last updated: Dec 31, 2019.

INTRODUCTION

Thyroid disease and thyroid surgery present specific challenges for anesthesiologists.

This topic reviews the perioperative anesthetic management of patients with thyroid disease and
anesthetic management of patients who undergo thyroid or parathyroid 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 "Thyroidectomy" and "Thyroid
storm".)

Perioperative risk as it relates to the degree of thyroid dysfunction is also discussed separately.
(See "Nonthyroid surgery in the patient with thyroid disease", section on 'Surgical outcomes' and
"Nonthyroid surgery in the patient with thyroid disease", section on 'Clinical manifestations that
may impact perioperative outcome'.)

Parathyroidectomy may be performed for patients with primary or secondary hyperparathyroidism.

Clinical manifestations of hyperparathyroidism and indications for surgery are discussed
separately. (See "Primary hyperparathyroidism: Clinical manifestations" and "Primary
hyperparathyroidism: Management" and "Refractory hyperparathyroidism and indications for
parathyroidectomy in adult dialysis patients" and "Management of secondary hyperparathyroidism

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in adult nondialysis patients with chronic kidney disease".)

MULTIORGAN SYSTEM EFFECTS OF THYROID DISEASE

Patients with existing hyper- or hypothyroidism have associated physiologic changes that may
affect anesthetic care and perioperative outcomes. Most such changes resolve with treatment as
the patient becomes euthyroid.

Hyperthyroidism — Hyperthyroidism can be classified as subclinical (ie, low thyroid-stimulating

hormone [TSH] with normal free T4 and T3), or overt (ie, suppressed TSH with elevated free T4
and/or T3). As the degree of hyperthyroidism increases, clinical manifestations are more prominent
and have a greater potential impact on anesthetic care. In patients with overt hyperthyroidism
surgery can, rarely, precipitate thyroid storm, a potentially life-threatening condition. (See
"Overview of the clinical manifestations of hyperthyroidism in adults" and "Nonthyroid surgery in
the patient with thyroid disease", section on 'Overt hyperthyroidism'.)

● 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 (table 1). Patients with hyperthyroidism are also prone to sinus
tachycardia and atrial fibrillation, coronary spasm, and ischemia, and may develop
cardiomyopathy over time [1-9]. (See "Cardiovascular effects of hyperthyroidism".)

● Hyperthyroidism does not increase minimum alveolar concentration (MAC) requirement

[10,11]. However, induction of anesthesia may be slower and may require increased
concentrations of inhaled anesthetics because of elevated cardiac output in patients with
hyperthyroidism, and resultant effects on uptake and distribution of anesthetics. Patients with
hyperthyroidism may have increased anesthetic requirements, primarily to control blood
pressure and heart rate. There are no existing data supporting an increased MAC with
contemporary inhaled anesthetics. Older animal studies demonstrated no clinically significant
increase in halothane requirements [11]. (See "Inhalation anesthetic agents: Properties and
delivery", section on 'Cardiovascular factors'.)

● Vasoactive medications should be chosen based on clinical and patient factors, independent
of thyroid function (table 2 and table 3).

Patients with hyperthyroidism have been thought to exhibit increased sensitivity to

catecholamines. Thus, the typical recommendation is that hypotension should be treated with

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direct acting vasoconstrictors (eg, phenylephrine) rather than with catecholamines or

medications that release catecholamines (eg, ephedrine). However, evidence in support of
this recommendation is indirect and conflicting. Some in vitro human studies have reported an
increase in beta adrenergic receptor density in the heart in patients with hyperthyroidism
[12-14]. However, there is also evidence that the increased receptor density may be
counteracted to a degree by cellular changes that reduce adrenergic receptor responsiveness
to catecholamines [15]. The net effect may be that cardiac adrenergic responsiveness is
unaltered in patients with hyperthyroidism. (See "Cardiovascular effects of hyperthyroidism",
section on 'Adrenergic effects'.)

● Respiratory muscle weakness occurs with hyperthyroidism, and in patients with severe
hyperthyroidism, this may mandate postoperative mechanical ventilatory support after general
anesthesia [16,17]. (See "Respiratory function in thyroid disease".)

Intraoperative thyroid storm — Thyroid storm is a rare, life-threatening condition

characterized by severe clinical manifestations of thyrotoxicosis [18]. It has been reported during
surgery and in the first 18 hours after thyroid and non-thyroid surgery in hyperthyroid patients,
though the incidence is very low in patients who receive preoperative antithyroid treatment. (See
"Nonthyroid surgery in the patient with thyroid disease", section on 'Thyroid storm'.)

The diagnosis of thyroid storm is based upon the presence of severe and life-threatening signs
and symptoms (eg, hyperthermia, cardiac dysfunction, altered mentation) in a patient with
biochemical evidence of hyperthyroidism. (See "Thyroid storm", section on 'Diagnosis'.)

During anesthesia, thyroid storm can be difficult to differentiate from malignant hyperthermia,
which may share clinical characteristics.

● If clinical signs of thyroid storm develop during or shortly after surgery in a patient with known
hyperthyroidism, therapeutic measures should be initiated immediately, including
administration of a beta blocker unless contraindicated. An endocrinologist should be
consulted urgently, and further treatment will likely include administration of a thionamide (eg,
methimazole or propylthiouracil), though these drugs cannot readily be administered
intravenously (see "Thyroid storm", section on 'Thionamides'). Other supportive measures
include aggressive treatment of hyperpyrexia with cooling blankets and acetaminophen,
administration of a glucocorticoid (eg, hydrocortisone), and treatment of metabolic
abnormalities.

● In patients without known hyperthyroidism, and prior to laboratory confirmation of

hyperthyroidism, it is reasonable to also manage the patient for malignant hyperthermia crisis

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(ie, administer dantrolene and discontinue potent inhaled anesthetics). (See "Malignant
hyperthermia: Diagnosis and management of acute crisis", section on 'Acute management of
suspected MH' and "Malignant hyperthermia: Diagnosis and management of acute crisis",
section on 'Others'.)

Ongoing support and monitoring in the critical care setting is strongly recommended since the
mortality rate is substantial in patients with thyroid storm [19]. (See "Thyroid storm", section on
'Treatment' and "Nonthyroid surgery in the patient with thyroid disease", section on 'Thyroid
storm'.)

Hypothyroidism — Hypothyroidism may be classified as mild, moderate, or severe, as follows:

● Mild hypothyroidism – Subclinical, elevated TSH with normal serum free T4

● Moderate hypothyroidism – Elevated TSH, low free T4, without clinical features of severe
hypothyroidism

● Severe hypothyroidism – Severe clinical symptoms such as altered mentation, pericardial

effusion, or heart failure; myxedema coma; or very low levels of total T4 (eg, <1.0 mcg/dL) or
free T4 (eg, <0.5 ng/dL). (See "Nonthyroid surgery in the patient with thyroid disease", section
on 'Defining the severity of hypothyroidism'.)

Severe hypothyroidism has a greater impact on anesthetic care than mild or well-treated
disease. Patients with moderate or severe hypothyroidism may exhibit exaggerated responses
to anesthetic agents, sedatives and opioids, and appear to be at increased risk of
perioperative complications. Case reports have described significant respiratory depression
from opioids, vasopressor-resistant hypotension, and prolonged recovery from anesthetic
agents in patients with severe hypothyroidism [20,21]. Studies of the pharmacokinetics and
pharmacodynamics of sedatives and anesthetic medications in these patients are lacking, and
it is unclear whether prolonged effects relate to reduced cardiac output and/or other
physiologic effects, or are a direct result of thyroid dysfunction [22]. There is no evidence that
these patients have a reduced MAC for contemporary inhaled anesthetics [23,24]. (See
"Nonthyroid surgery in the patient with thyroid disease", section on 'Defining the severity of
hypothyroidism' and "Nonthyroid surgery in the patient with thyroid disease", section on
'Surgical outcomes'.)

Physiologic effects of hypothyroidism that may affect anesthetic management include the following:

● Cardiovascular abnormalities may lead to perioperative hemodynamic instability or myocardial

ischemia. Clinically hypothyroid patients may have bradycardia, diminished response to

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adrenergic agents, diastolic dysfunction, increased systemic vascular resistance, and

impaired venous return (table 4) [1,2,25-27]. Patients with hypothyroidism, even subclinical
disease, are at increased risk for ischemic heart disease [28,29]. (See "Clinical manifestations
of hypothyroidism", section on 'Cardiovascular system'.)

● Hypothyroid patients may have a diminished response to alpha and beta adrenergic agents,
and larger than usual doses of vasopressors may be required [30-32]. (See "Cardiovascular
effects of hypothyroidism", section on 'Cardiac contractility'.)

● Obstructive sleep apnea is more common and should be suspected in patients with
hypothyroidism (see "Respiratory function in thyroid disease", section on 'Obstructive sleep
apnea'). Perioperative management of patients with obstructive sleep apnea is discussed
separately. (See "Surgical risk and the preoperative evaluation and management of adults
with obstructive sleep apnea" and "Intraoperative management of adults with obstructive sleep
apnea" and "Postoperative management of adults with obstructive sleep apnea".)

● Respiratory effects of the hypothyroid state include impaired ventilatory drive and respiratory
muscle weakness, which can lead to alveolar hypoventilation [33-35]. Also, hypothyroid
patients are extremely sensitive to the effects of drugs that depress respiratory drive, such as
opioids and sedatives [20,21,36].

● Patients with severe clinical hypothyroidism 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 [37]. Other concerns include hypoglycemia, anemia, and hypothermia.

PREANESTHESIA EVALUATION

Preanesthesia evaluation always includes a medical history and anesthesia-focused physical

examination, including airway examination. Testing should be determined by the patient's medical
status and the surgical procedure. Preanesthesia evaluation is discussed in detail separately. (See
"Preanesthesia evaluation for noncardiac surgery".)

Euthyroid patients — For patients with known, treated thyroid disease, clinical euthyroid status
should be confirmed during preanesthesia evaluation. 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",

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section on 'Is preoperative measurement of TSH necessary?'.)

Patients with abnormal thyroid function — If history and physical examination suggest thyroid
disease, it is reasonable to try to make a diagnosis, starting with laboratory thyroid function tests,
since it can affect perioperative management. (See "Diagnosis of and screening for hypothyroidism
in nonpregnant adults", section on 'Diagnosis' and "Diagnosis of hyperthyroidism", section on
'Diagnosis'.)

Elective surgery should be delayed in patients with recently diagnosed thyroid disease and in
those who remain hyperthyroid or severely hypothyroid, until treatment results in a documented
euthyroid state. If urgent or emergency 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'.)

For emergency surgery in patients with moderately severe or severe hypothyroidism, advanced
intraoperative monitoring (eg, continuous intraarterial blood pressure monitoring) may be indicated,
and such patients may require intensive care postoperatively. Preoperative thyroid hormone
replacement and postoperative concerns in such patients are discussed separately. (See
"Nonthyroid surgery in the patient with thyroid disease", section on 'Management'.)

Airway evaluation — Preanesthesia evaluation always includes an airway assessment with the
goal of predicting any potential difficulty with airway management (see "Airway management for
induction of general anesthesia", section on 'Airway assessment'). While an enlarged thyroid
(goiter) may cause airway compromise due to invasion of airway structures, extension into the
mediastinum, and compression of the trachea, we do not routinely order imaging studies
specifically to assess the airway in patients with thyroid disease or a goiter [38-40]. In two
prospective studies of intubation in thyroidectomy patients, difficult endotracheal intubation was
predicted most often by the usual anatomic predictive factors (table 5), rather than the size of the
goiter or the presence of tracheal compression or deviation [38,41]. In practice, the presence of a
large benign goiter without symptoms of obstruction seldom changes airway management plans.

Surgical evaluation prior to thyroidectomy usually includes laryngoscopy to evaluate vocal cord
function, as well as thyroid ultrasound (see "Thyroidectomy", section on 'Preoperative evaluation
and preparation'). 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, the extent of tracheal compression, and the location of the mass (eg, anterior or
posterior mediastinum) [40,42]. Other studies may have been ordered to evaluate the full extent of

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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 may be a risk factor for difficult
intubation, possibly due to tissue infiltration with associated fibrosis, which may reduce the
mobility of laryngeal structures and impede the view of the glottic opening during laryngoscopy
[38]. The limited literature on this issue is conflicting. In one prospective review of 320 patients
who underwent thyroidectomy, presence of a cancerous goiter was an independent risk factor
for difficult intubation [38]. In contrast, in another prospective study of 324 thyroidectomy
patients, thyroid malignancy was not associated with difficult intubation [41]. Neither study
provided details on the severity of thyroid malignancy or related imaging.

● 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 [40]. 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'.)

Substernal mediastinal goiters can cause obstruction of airway and major cardiovascular
structures with induction of anesthesia. (See 'Induction of anesthesia' below and "Anesthesia
for patients with an anterior mediastinal mass", section on 'Anesthetic preparation and
management'.)

ANESTHETIC MANAGEMENT FOR THYROID AND/OR PARATHYROID

SURGERY

Anesthetic management is generally similar for thyroid and parathyroid surgery, except as noted in
the following discussion.

Choice of anesthetic technique — Thyroid and parathyroid surgery (open or minimally invasive)
can be performed with general anesthesia or with local/regional anesthesia, which usually includes
a cervical plexus block. Excision of a single parathyroid gland can often be performed with local
infiltration alone, without a nerve block. The choice of anesthetic technique should be based on
patient factors and patient, surgeon, and anesthesiologist preference.

We prefer general anesthesia for thyroid or parathyroid surgery, unless local or regional anesthesia

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is requested by the patient and/or the surgeon. However, practice varies, and in some high volume
endocrine surgery centers, local or regional anesthesia is used more commonly than general
anesthesia [43,44]. General anesthesia provides a secure airway from the start of anesthesia and
an immobile surgical field. Regional anesthesia allows intraoperative voice monitoring, avoidance
of endotracheal intubation, and may have other benefits for patients with some comorbidities, such
as avoidance of hemodynamic changes in patients with cardiac disease. Several studies that
compared general with regional anesthesia for thyroid surgery have reported reduced length of
stay and costs with regional anesthesia, and similar clinical outcomes [43,45,46].

Surgical contraindications to a local/regional anesthetic technique include a plan for sternotomy or

lateral neck dissection. Patient factors that are contraindications for local/regional anesthesia
include cervical lymphadenopathy, locally invasive cancer, local anesthetic allergy, and patient
refusal. [44,47]. General anesthesia is usually preferred for prolonged surgical procedures, for
patients who cannot communicate, cooperate, or lie still or with their neck extended for the length
of the surgery, for patients with severe anxiety, and for patients who are claustrophobic. General
anesthesia with secure airway control may also be preferred for patients with predicted difficulty
with airway management, or expected airway difficulty during sedation (eg, patients with
obstructive sleep apnea or morbid obesity). In large case series, 2 to 12 percent of patients
undergoing thyroidectomy with local or regional anesthesia require conversion to general
anesthesia because of anxiety, inadequate anesthesia, surgical difficulty, or airway problems
[44,46,47].

Local/regional anesthesia can be used for minimally invasive thyroid surgery, unless alternative
incision sites are used (eg, axillary or retroauricular). (See "Thyroidectomy", section on 'Minimally
invasive thyroid surgery'.)

Local or regional anesthesia — Regional anesthesia for thyroid or parathyroid surgery usually
involves the use of a cervical plexus block along with local infiltration by the surgeon, as well as
monitored anesthesia care and sedation. Superficial cervical plexus block is the regional
anesthetic technique of choice for thyroid and parathyroid surgery. Deep cervical plexus block is
more difficult to perform, less effective, and associated with more anesthesia-related complications
than superficial block. (See "Scalp block and cervical plexus block techniques", section on
'Cervical plexus blocks'.)

Pain is usually modest after uncomplicated thyroidectomy, and cervical plexus blocks are not
indicated solely for postoperative analgesia after thyroidectomy. A meta-analysis of randomized
trials found no clinically significant reduction in postoperative pain from addition of superficial
cervical plexus block to general anesthesia [48].

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Intraoperative anesthetic management

Monitoring — Standard physiologic monitoring (ie, electrocardiography, noninvasive blood

pressure monitoring, pulse oximetry, and capnography) is sufficient for most patients who undergo
thyroid or parathyroid surgery (table 6). Advanced monitoring (eg, intra-arterial continuous blood
pressure monitoring) may be indicated based on patient comorbidities. Special monitoring that
may be used during these procedures include the following:

Recurrent laryngeal nerve monitoring — If recurrent laryngeal nerve monitoring is to be

used during the procedure, either a specialized endotracheal tube (ETT) may be used, or a
conventional ETT with electrodes applied above the ETT cuff. The electrodes must be placed at
the level of the vocal cords during intubation. Neuromuscular blockade should then be avoided
during maintenance of anesthesia. Intraoperative nerve monitoring is discussed separately. (See
"Thyroidectomy", section on 'Intraoperative nerve monitoring'.)

Parathyroid hormone monitoring — Intraoperative parathyroid hormone monitoring may

be performed during parathyroidectomy for hyperparathyroidism, to indicate when hyperfunctioning
parathyroid tissue has been excised. One or more blood samples can be drawn from a peripheral
vein, an arterial catheter, or by the surgeon from the internal jugular vein. The decision to place an
arterial catheter or a second intravenous (IV) catheter should be individualized; we usually draw
the necessary sample from a vein in the foot or lower leg for these samples, since the patient's
arms are tucked at the side and inaccessible. Another common approach is to place an IV catheter
in an antecubital vein just below a blood pressure cuff (and use the cuff as a tourniquet prior to
withdrawing a blood sample). Some surgeons simply prefer to draw a sample from the internal
jugular vein in the operative field. (See "Parathyroid exploration for primary hyperparathyroidism",
section on 'Intraoperative parathyroid hormone monitoring'.)

Induction of anesthesia — The choice of induction technique and medications depends on

patient factors, and is discussed separately. (See "Induction of general anesthesia: Overview".)

If nerve monitoring is to be used during the procedure, neuromuscular blockade must be avoided
during testing. Thus a short-acting neuromuscular blocking agent (NMBA), or no NMBA, should be
used for endotracheal intubation. Options include succinylcholine, rocuronium or vecuronium
reversed with sugammadex prior to testing, or a remifentanil intubation (eg, remifentanil 2.5 to 4
mcg/kg IV with propofol 2 mg/kg IV and ephedrine 10 to 15 mg IV, modified for patient factors).
(See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Alternatives to
succinylcholine'.)

Substernal goiters are present in 2 to 19 percent of patients having thyroidectomy [49], and are

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located in the anterior mediastinum in 75 to 90 percent of cases [50]. Induction of anesthesia in

patients with a very large or obstructing mediastinal mass may result in obstruction of major
airways or major cardiovascular structures. Management of anesthesia for patients with
mediastinal masses is discussed separately. (See "Anesthesia for patients with an anterior
mediastinal mass".)

Airway management — We routinely perform endotracheal intubation for thyroid or parathyroid

surgery, though supraglottic airways (SGAs) can be used for these procedures as well [51-53].

ETTs provide a secure airway throughout the procedure, and are mandatory if recurrent laryngeal
nerve monitoring is used. SGAs are more likely to require adjustment after neck extension for
surgical positioning or during tracheal manipulation during surgery, but may result in less coughing
during emergence from anesthesia.

The airway may be managed with standard intubation techniques in most patients with thyroid
disease. However, for patients with a goiter that is symptomatic, invasive, or substernal, the
approach to induction and intubation may need to be altered. (See 'Airway evaluation' above and
"Management of the difficult airway for general anesthesia in adults".)

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 (which may be difficult in a patient with a
goiter) or rigid bronchoscopy for patients with airway compromise [40]. (See "Management of the
difficult airway for general anesthesia in adults", section on 'Awake intubation'.)

Positioning for surgery — The patient is typically positioned on the operating table in a supine
position with the head elevated, with the arms tucked at the sides. The neck is typically extended,
with either a roll or an inflatable bag (ie, a "thyroid bag") under the patient's shoulders. The
patient's ability to extend the neck should be assessed preoperatively, and patients with known
cervical spine disease should be assessed by an orthopedic surgeon or neurosurgeon for the
safety of neck extension. (See "Thyroidectomy", section on 'Patient position and skin preparation'.)

● After positioning, the patient's occiput should be resting on a head support (eg, foam donut or
blanket), rather than floating or suspended.

● The airway device may require adjustment after positioning with neck extension. Neck
extension may move the electrodes for nerve monitoring of the ETT out of correct position
relative to the vocal cords and can unseat an SGA.

Maintenance of anesthesia — The choice of anesthetic agents for maintenance of anesthesia

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depends on patient factors, and is discussed separately. (See "Maintenance of general anesthesia:
Overview".)

The effects of abnormal thyroid function on the choice of anesthetic agents and intraoperative
management are discussed above. (See 'Multiorgan system effects of thyroid disease' above.)

Concerns specific to thyroid or parathyroid surgery include the following:

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

● Manipulation of the trachea during surgery is stimulating, and can cause cough or patient
movement. Remifentanil infusion (eg, 0.03 to 0.3 mcg/kg per minute, modified for patient
factors and other anesthetic agents) can be used to suppress these responses without
unnecessary postoperative opioid effect. Low dose remifentanil infusion can also be
administered during emergence and extubation to minimize cough. (See 'Emergence and
extubation' below.)

● We use standard oxygen supplementation for patients who undergo thyroid or parathyroid
surgery, with fraction of inspired oxygen typically approximately 30 percent, modified for
patient factors (see "Mechanical ventilation during anesthesia in adults", section on 'Fraction
of inspired oxygen'). Whereas 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 [54].

Prophylaxis for postoperative nausea and vomiting — We employ preventive measures for
postoperative nausea and vomiting for all patients who undergo thyroid surgery to minimize the
risk of wound hematoma due to retching or vomiting. We administer at least one prophylactic
antiemetic during surgery (eg, ondansetron 4 mg IV), and use an opioid-sparing strategy for
postoperative pain relief (eg, local anesthetic wound infiltration, postoperative acetaminophen and
nonsteroidal antiinflammatory drugs). In high-risk patients, we also use total IV anesthesia. (See
"Postoperative nausea and vomiting".)

Emergence and extubation — Severe hypertension or coughing during emergence and

extubation may induce bleeding from the surgical site, with possible hematoma formation.
Strategies to minimize coughing include, but are not limited to, extubation under deep anesthesia
(which carries the risks of an unprotected airway in an anesthetized patient) or administration of
remifentanil, dexmedetomidine, or lidocaine during emergence [55-57]. The choice of technique
and drugs is determined by patient risk factors for coughing (eg, smoking status), as well as the
preferences and the experience of the anesthesiologist. (See "Extubation following anesthesia",

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section on 'Minimizing physiologic response to extubation'.)

Postextubation airway complications — 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 compression
(extremely rare); or expansion of a cervical wound hematoma, causing new tracheal compression.
Immediate reintubation may be necessary. (See "Thyroidectomy", section on 'Hematoma' and
"Thyroidectomy", section on 'Nerve injury/vocal cord paresis or paralysis'.)

Recurrent laryngeal nerve injury — All patients who undergo thyroid or parathyroid
surgery should be watched closely immediately after extubation for signs of recurrent laryngeal
nerve (RLN) dysfunction, including stridor, weak vocalization, or airway obstruction, particularly
after bilateral surgery. RLN injury may be suspected by the surgeon or suggested by nerve
monitoring, but may be apparent only after extubation without intraoperative evidence of injury.

The RLN innervates most of the intrinsic laryngeal muscles. Injury to the nerve can be partial and
result in weak vocal cord motion, or complete and result in paralysis of the affected vocal cord. The
involved vocal cord assumes a median or paramedian position. Unilateral RLN injury causes
hoarseness but no airway obstruction, whereas bilateral RLN paralysis can result in stridor, and
possibly complete airway obstruction. Immediate reintubation, and occasionally tracheostomy, may
be necessary. (See "Thyroidectomy", section on 'Nerve injury/vocal cord paresis or paralysis'.)

Injury to the superior laryngeal nerve (in contrast with the RLN) has no effect on postoperative
airway status. Rather, it manifests as voice fatigue and changes in voice quality [58].

Neck hematoma — Postoperative neck hematoma requiring emergency 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 soft tissue swelling
develops and as the hematoma expands. When surgical bleeding causes airway compromise,
emergency 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 [59,60]. (See "Thyroidectomy",
section on 'Hematoma'.)

If time permits, the patient should be returned to the operating room for re-exploration; however,
rapidly developing airway compromise may require bedside evacuation of the hematoma as an
immediate airway protection maneuver. Soft tissue swelling may be so severe that reopening the
incision fails to fully normalize the airway anatomy. Since substantial distortion of the airway may

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persist after the hematoma has been evacuated, the safest method for intubation may be an
awake intubation. No matter what approach is taken, intubation should not be delayed; it should be
performed expeditiously by the most experienced member of the team (table 7).

Tracheomalacia — Longstanding tracheal compression by a goiter may lead to

tracheomalacia [50]. Although extremely 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 patients with longstanding large goiters, we perform a cuff leak test to assess the adequacy of
air flow around the endotracheal tube prior to extubation (see "Extubation following anesthesia",
section on 'Cuff-leak test'). If there is no leak, we extubate over a tube exchanger to facilitate rapid
reintubation if necessary.

Postoperative care — Most patients are transferred to the post-anesthesia care unit for recovery
from anesthesia, with monitoring and discharge criteria similar to patients who have other types of
surgery. These issues are discussed separately. (See "Overview of post-anesthetic care for adult
patients".)

After thyroid surgery, patients may be admitted to the hospital for overnight observation and
management, or in select cases, may be discharged home within a few hours of surgery. Inpatient
versus outpatient surgery is discussed separately. (See "Thyroidectomy", section on 'Inpatient
versus outpatient surgery'.)

SUMMARY AND RECOMMENDATIONS

● Thyroid dysfunction causes physiologic changes that may affect anesthetic care and
perioperative outcomes. Most of these changes resolve with treatment as the patient becomes
euthyroid. (See 'Multiorgan system effects of thyroid disease' above.)

● For patients with known, treated thyroid disease, euthyroid status should be confirmed during
preanesthesia evaluation. 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 'Euthyroid patients' above.)

● For patients with recently diagnosed thyroid disease, elective surgery should be delayed until
treatment results in a documented euthyroid state. Patients with severe hypothyroidism or
hyperthyroidism who need urgent or emergency surgery should receive immediate treatment
prior to surgery. (See 'Patients with abnormal thyroid function' above.)

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● We prefer general anesthesia for thyroid or parathyroid surgery. Advantages of general

anesthesia include secured 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 gland (goiter) can cause difficulty with airway management for anesthesia,
particularly cancerous, substernal, or obstructing goiters. (See 'Airway evaluation' above.)

● A smaller than usual endotracheal tube (ETT) size may be required in patients with potential
airway problems related to a goiter. 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 of anesthesia' above.)

● If recurrent laryngeal nerve monitoring is used during thyroid or parathyroid surgery,

neuromuscular blockade should be avoided during testing. (See 'Recurrent laryngeal nerve
monitoring' 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 emergency surgical decompression of any wound
hematoma. (See 'Postextubation airway complications' above.)

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52. Chun BJ, Bae JS, Lee SH, et al. A prospective randomized controlled trial of the laryngeal
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53. Gong Y, Wang J, Xu X, et al. Performance of Air Seal of Flexible Reinforced Laryngeal Mask
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54. Schietroma M, Piccione F, Cecilia EM, et al. How does high-concentration supplemental
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55. Lee B, Lee JR, Na S. Targeting smooth emergence: the effect site concentration of
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for thyroid surgery. Br J Anaesth 2009; 102:775.

56. 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
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57. Lee JH, Koo BN, Jeong JJ, et al. Differential effects of lidocaine and remifentanil on response
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58. Rosato L, Avenia N, Bernante P, et al. Complications of thyroid surgery: analysis of a

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Topic 91383 Version 25.0

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GRAPHICS

Cardiovascular effects of hyperthyroidism

Parameter Finding

Heart rate Increased

Pulmonary artery pressure Increased

Systemic vascular resistance Decreased

Cardiac output Increased

Ejection fraction Increased

Diastolic relaxation Increased

Systolic blood pressure Increased

Diastolic blood pressure Decreased

Myocardial oxygen consumption Increased

Anginal syndrome Can induce or worsen

Graphic 56219 Version 3.0

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Drugs used to lower blood pressure in the operating room: Adult dosing* ¶

Functional
class
Drug (predominant Bolus dose Infusion dose Comments
receptor or
mechanism)

Beta blocking agents – Generally avoided in patients with acute decompensated heart failure

Esmolol Beta 1 -selective 10 to 50 mg, which 50 to 300 mcg/kg Rapid onset and very short
adrenergic receptor may be repeated /minute duration of action
blockade (every 5 to 15 Clearance is not dependent
minutes depending on renal or hepatic function
upon the initial dose due to rapid metabolism by
used, the desired plasma esterases
effect, and the
patient's risk for
hemodynamic
decompensation)

Metoprolol Beta 1 -selective 1 to 5 mg, followed N/A Commonly used agent to

adrenergic receptor by 2.5 to 15 mg treat suspected myocardial
blockade every 3 to 6 hours ischemia due to
tachycardia with normal or
elevated blood pressure

Labetalol Blockade of Initial bolus of 5 to 0.5 to 2 Often selected as a first-

postsynaptic 25 mg, which may mg/minute up to a line agent to treat
alpha 1 -adrenergic be followed by maximum of 10 concomitant hypertension
receptors and non- repeated boluses mg/minute and tachycardia
selective beta every 10 minutes (generally reserved Use cautiously in patients
blockade for beta 1 - (up to 300 mg) for hypertensive with obstructive or reactive
and beta 2 - emergencies) airway disease
adrenergic receptors Avoid in hyperadrenergic
states (eg,
pheochromocytoma or
cocaine or
methamphetamine
overdose) since beta
blockade and loss of
beta 2 -mediated
vasodilation induced by
labetalol can lead to severe
hypertension when prior
alpha 1 -adrenergic
blockade is incomplete

Calcium channel blocking agents – Use cautiously in patients with increased ICP

Nicardipine* Selective 100 to 500 mcg 5 to 15 mg/hour Predominantly arteriolar

dihydropyridine-type vasodilator
calcium channel Commonly used for
blocker; selective neurosurgical patients
arteriolar smooth
muscle relaxation

Clevidipine Selective N/A Initial dose 1 to 2 Rapid onset and short

dihydropyridine-type mg/hour, with duration of action
calcium channel rapid titration up Clearance is not dependent

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blocker; selective to 16 mg/hour on renal or hepatic function

arteriolar smooth due to rapid metabolism by
muscle relaxation plasma esterases

Direct vasodilators (direct relaxation of vascular smooth muscle) – Generally avoided in patients with
increased ICP

Hydralazine Highly selective Initial bolus of 2.5 N/A Minimal or no effect on the
vasodilation of mg followed by venous circulation
arterial resistance repeated boluses Relatively slow onset
vessels every 5 minutes to compared with other
a maximum 20 mg antihypertensive agents

Nitroglycerin Nitrodilator that 10 to 40 mcg, 10 to 200 Continuous monitoring

(glyceryl causes increased which may be mcg/minute using an intra-arterial
trinitrate) release of NO, repeated and/or or catheter is warranted as
resulting in smooth followed by infusion soon as feasible,
0.1 to 3 mcg/kg
muscle relaxation particularly if higher doses
/minute
are used
SL or paste forms of
nitroglycerin paste (1 to 2
inches) formulations also
available

Nitroprusside Nitrodilator that N/A 10 to 200 Continuous monitoring

directly releases NO, mcg/minute using an intra-arterial
resulting in smooth or catheter is necessary
muscle relaxation Cyanide accumulation may
0.1 to 3 mcg/kg
occur
/minute

Other antihypertensive agents

Fenoldopam Selective agonist for N/A Initial dose at 0.1 Rarely used in
D 1 dopamine mcg/kg/minute perioperative settings
receptors; binds titrated up to a Generally avoided in
with moderate maximum of 1.6 patients with glaucoma or
affinity to alpha 2 - mcg/kg/minute increased ICP
adrenoceptors

N/A: not applicable; ICP: intracranial pressure; NO: nitric oxide; SL: sublingual.
* Dose ranges are based on adult patients of normal size.
¶ Refer to related UpToDate content on hemodynamic management during anesthesia.

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Vasopressors and inotropic agents used in the operating room: Adult dosing* ¶

Functional
class
(predominant Bolus
Drug Infusion dose Comments
receptor or dose
mechanism of
action)

Ephedrine Inotrope/chronotrope 5 to 10 mg N/A Tachyphylaxis may occur

/vasopressor boluses with multiple repeated
(alpha 1 -adrenergic doses due to indirect
receptor agonist; postsynaptic release of
beta 1 - and beta 2 - norepinephrine
adrenergic receptor Cardiovascular effects
agonist) attenuated by drugs that
block ephedrine uptake
into adrenergic nerves
(eg, cocaine) or those
that deplete
norepinephrine reserves
(eg, reserpine)
Administered with
extreme caution (eg, in
small incremental doses
of 2.5 mg) to patients
using monoamine oxidase
(MAO) inhibitors or
methamphetamines since
exaggerated hypertensive
responses or life-
threatening dysrhythmias
may occur

Phenylephrine Vasopressor 50 to 100 10 to 100 mcg/minute Often selected to treat

(alpha 1 -adrenergic mcg boluses or hypotension if normal or
receptor agonist) (may begin elevated HR is present
0.1 to 1 mcg/kg/minute
infusion if Genetic polymorphisms
repeated lead to variable individual
bolus doses responses
are
necessary)

Norepinephrine Inotrope/vasopressor 4 to 8 mcg 1 to 20 mcg/minute Often selected as a first-

(alpha 1 - and beta 1 - (may begin or line agent during
adrenergic receptor infusion if noncardiac surgery,
0.01 to 0.3 mcg/kg/minute
agonist) repeated particularly for treatment
bolus doses of most types of shock
are Norepinephrine 8 mcg is
necessary) approximately equivalent
in potency to
phenylephrine 100 mcg
Peripheral extravasation
of a high concentration
may cause tissue damage

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Epinephrine Inotrope/chronotrope 4 to 10 mcg 1 to 100 mcg/minute
/vasopressor initially; up or
(alpha 1 -adrenergic to 100 mcg
0.01 to 1 mcg/kg/minute
receptor agonist; boluses may
beta 1 - and beta 2 - be used
adrenergic receptor when initial Note changing effects
agonist) response is across dose range:
inadequate Low doses have
primarily beta 2 -
adrenergic effects at
1 to 2 mcg/minute or
0.01 to 0.02 mcg/kg
/minute
Intermediate doses
have primarily beta 1 -
and beta 2 -adrenergic
effects at 2 to 10
mcg/minute or 0.02
to 0.1 mcg/kg/minute
High doses have
primarily alpha 1 -
adrenergic effects at
10 to 100
mcg/minute or 0.1 to
1 mcg/kg/minute
Vasopressin Vasopressor 1 to 4 units 0.01 to 0.04 units/minute
(vasopressin 1 and
vasopressin 2
Doses >0.04 units/minute
receptor agonist)
up to 0.1 units/minute are
reserved for salvage
therapy (ie, failure to
achieve adequate BP goals
with other vasopressor
agents) ¶
Dopamine Inotrope/vasopressor N/A 2 to 20 mcg/kg/minute
/dose-dependent
chronotropy
Note changing effects
(dopaminergic,
across dose range:
beta 1 -, beta 2 -, and
alpha 1 -adrenergic Low doses have
receptor agonist) primarily
dopaminergic effects
at <3 mcg/kg/minute
Intermediate doses
have primarily beta 1 -
and beta 2 -adrenergic
effects at 3 to 10
mcg/kg/minute
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First-line treatment for
cardiac arrest and for
anaphylaxis
May be administered IV,
IM, or via an
endotracheal tube in
emergencies
Low doses cause
bronchodilatory effects
and may cause arterial
vasodilation and
decreased BP
Intermediate doses cause
increases in HR and BP
High doses cause
vasoconstriction, with
possible severe
hypertension and adverse
metabolic effects
Individual responses to
dose-related effect are
variable
Effective for treatment of
hypotension refractory to
administration of
catecholamines or
sympathomimetics such
as ephedrine,
phenylephrine, or
norepinephrine
No direct effect on HR
Little effect on PVR; can
cause splanchnic
vasoconstriction
Individual responses to
dose-related effects are
variable
Peripheral extravasation
may cause skin necrosis
Low doses may
exacerbate hypotension
via beta 2 stimulation
High doses may cause
vasoconstriction, adverse
metabolic effects, and
arrhythmias
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High doses have

Dobutamine Inotrope/vasodilator N/A primarily
1 to 20 alpha 1 -
mcg/kg/minute Exacerbation of
/dose-dependent adrenergic effects hypotension is possible
chronotropy (beta 1 - >10 mcg/kg/minute due to dose-dependent
and beta 2 - vasodilation (via beta 2
adrenergic receptor stimulation); concurrent
agonist) administration of a potent
vasoconstrictor such as
norepinephrine or
vasopressin may be
necessary

Milrinone Inotrope/vasodilator N/A 0.375 to 0.75 mcg/kg Exacerbation of

(phosphodiesterase /minute (a loading dose of hypotension is likely due
inhibitor) (decreases 50 mcg/kg over ≥10 to vasodilation (via
rate of cyclic minutes may be phosphodiesterase
adenosine administered, but is often inhibition); concurrent
monophosphate omitted) administration of a potent
[cAMP] degradation) vasoconstrictor such as
norepinephrine or
vasopressin may be
necessary

Isoproterenol Inotrope/chronotrope N/A 5 to 20 mcg/minute Exacerbation of

/vasodilator (beta 1 - or hypotension is likely due
and beta 2 - to dose-dependent
0.05 to 0.2 mcg/kg/minute
adrenergic receptor vasodilation (via beta 2
agonist) stimulation)
May cause arrhythmias
Not available in most
settings

N/A: not applicable; HR: heart rate; IV: intravenous; IM: intramuscular; BP: blood pressure; PVR: pulmonary vascular
resistance.
* Dose ranges are based on adult patients of normal size.
¶ Refer to related UpToDate content on hemodynamic management during anesthesia and surgery.

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Hypothyroidism and the heart

Parameter Finding

Systemic vascular resistance Increased

Cardiac output Decreased

Blood pressure

Systolic Decreased or normal

Diastolic Increased or normal

Heart rate Decreased or normal

Cardiac contractility Decreased

Cardiac mass Decreased

Blood volume Decreased

Ventricular arrhythmias Can induce or worsen

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Predictors of difficult endotracheal intubation (by direct laryngoscopy)

Prior difficult intubation

Interincisor (intergingival edentulous patients) gap (<4 cm)

Thyromental distance (<6 cm)

Sternomental distance (<12 cm)*

Head and neck extension (<30 degrees from neutral)

Mallampati oropharyngeal classification (class 3 or 4)

Mandibular protrusion (inability to prognath)*

Neck circumference (>40 cm)*

Sub-mental compliance (hard and noncompliant)*

Physical findings predictive of difficult endotracheal intubation. The greater the number of positive findings, the
more likely intubation by direct laryngoscopy will be difficult. The highest positive predictive value comes from a
history of difficulty with intubation, or findings of a short thyromental distance or decreased range of motion of the
neck.

* Also predicts difficult video laryngoscopy (in addition to large tonsils and epiglottis and history of Cormack and Lehane
grade 3 or 4 at direct laryngoscopy).

Information from:
1. Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip
bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope Anesth Analg 2008;
106:1495.
2. Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness of the Glidescope in difficult airway
management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions.
Anesthesiology 2011; 114:34.
3. Hung OR, Pytka S, Morris I, et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea.
Anesthesiology 1995; 83:509.
4. Hung OR, Pytka S, Morris I, et al. Lightwand intubation: II--Clinical trial of a new lightwand for tracheal intubation
in patients with difficult airways. Can J Anaesth 1995; 42:826.

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Basic monitoring during anesthesia

Primary physiologic
Monitoring Derived Additional
process/parameter Principle
equipment information function
targeted

Oxygenation Inspired O 2 analyzer Paramagnetic sensor, Inspired/expired A low-level alarm is

gas O 2 (with a low- fuel (galvanic) cell, O 2 concentration automatically
content limit alarm in polarographic (Clark) when placed activated by turning
use) electrode, mass downstream from on the anesthesia
spectroscopy, or fresh flow control machine
Raman scattering valves

Blood Pulse oximeter The Beer-Lambert law Hemoglobin Continuous

oxygenation applied to tissues and saturation, pulse evaluation of
pulsatile blood flow. rate, relative pulse circulation, variable
The relative amplitude displayed pitch pulse tone,
absorbency at on and audible low-
wavelengths of 660 plethysmography threshold alarm
and 940 nm is used waveform
to estimate
saturation, which is
derived from the ratio
of oxyhemoglobin to
the sum of
oxyhemoglobin plus
deoxyhemoglobin.

Ventilation Exhaled Capnograph CO 2 molecules ETCO 2 , inspired Instantaneous

CO 2 absorb infrared CO 2 , diagnostic information about:
radiation at 4.26 waveforms, Perfusion (how
micrometers, respiratory rate, effectively CO 2 is
proportionate to the apnea detection being transported
CO 2 concentration through the
present in the breath vascular system)
sample Metabolism (how
effectively CO 2 is
being produced
by cellular
metabolism)
Confirmation of
tracheal tube
placement after
intubation

Integrity of Disconnection Detects the cyclical Alarms if a Alarms if high

ventilation alarm changes in airway significant decrease pressures are
system pressure in the in rate or pressure sensed
during normal range occurs
mechanical
ventilation

Pulmonary Pulmonary Volume of gas Inspired and Pressure volume

mechanics flow and proportional to a expired volume, and flow volume
(volume, pressure drum movement, flow, and airway loops
flow, sensors changes in differential pressure
pressure) pressure (near the
Y-connector) or in
electrical resistance
(hot wire housed in a

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monitor or ventilator)

Circulation Cardiac ECG The ECG monitor Heart rate and ST segment
activity detects, amplifies, rhythm depression/elevation
displays, and records and trend over time,
the ECG signal. with an audible
alarm warning of
significant
arrhythmias or
asystole

Arterial BP Noninvasive Oscillometric devices Arterial BP Indicator of organ

BP monitor automatically inflate perfusion
and deflate the cuff,
and have electronic
pressure sensors that
record the pressure
oscillations of the
arteries. The pressure
at which maximal
oscillations occur as
the cuff is deflated
corresponds with
MAP. Proprietary
algorithms are used
to calculate systolic
and diastolic BP.

Temperature Temperature Devices with a Core or peripheral A greater than 2°C

monitor semiconductor, temperature core-to-periphery
electrical resistance temperature
decreases as gradient is indicative
temperature of low cardiac
decreases output.

O 2 : oxygen; CO 2 : carbon dioxide; ETCO 2 : end-tidal carbon dioxide; ECG: electrocardiogram; BP: blood pressure; MAP:
mean arterial pressure.

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Airway management for patients with airway compression

Awake intubation is recommended if the patient is cooperative, stable, and can maintain spontaneous ventilation,
airway patency, and adequate O 2 saturation.

Personnel able to perform a surgical airway should be prepared to immediately intervene should life-threatening
airway obstruction occur.

Consider opening the wound if an expanding postoperative neck hematoma is suspected.

Maintain spontaneous ventilation with induction of GA.

Position tracheal tube below level of obstruction. Fiberoptic confirmation may be required.

SGA is not recommended.

VAL and FSI are good choices as long as they allow visualizing airway.

O 2 : oxygen; GA: general anesthesia; SGA: supraglottic airway devices; VAL: video-assisted laryngoscopy; FSI: flexible
scope intubation.

Reproduced with permission from: Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma: Updated by
COTEP. ASA Monitor 2014; 78:56. Copyright © 2014 American Society of Anesthesiologists. Excerpted from ASA Monitor
(2014) of the American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American
Lane, Schaumburg, IL, 60173-4973 or online at www.asahq.org.

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Contributor Disclosures
William R Furman, MD Nothing to disclose Amy C Robertson, MD Nothing to disclose Stephanie B
Jones, MD Spouse/Partner Disclosure: Consultant/Advisory Board: Allurion Inc [gastric balloon for non-
surgical weight loss]. Marianna Crowley, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

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