Anesthesia for thyroid

surgeries
Facilitator: DR. HAKOLO
Presenters: ENOS MASELE -2020-04-14284

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OUTLINES;
• Introduction.
• Anatomy and Physiology of the thyroid gland.
• Pre operative assessment.
• Intra operative management.
• Post operative management.
• Complications.

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INTRODUCTION

• Thyroid gland is anEndocrine gland in the anterior and lateral aspects of the
neck, located beneath the larynx (vocal voice) .
• It makes thyroid hormone and calcitonin.
• Innervated by Adrenergic and cholinergic nervous system.
• It is highly vascular gland with rich capillary permeation
• The gland is made up of follicles with proteinaceous colloid.
• The hypothalamo-pituitary-thyroid axis play an important role in
metabolism.
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Anatomical location of thyroid gland.
• The thyroid gland lies posterior to the sternothyroid and sternohyoid
muscles, wrapping around the cricoid cartilage and tracheal rings. It is
located inferior to the laryngeal thyroid cartilage, typically
corresponding to the vertebral levels C5-T1.

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Thyroid disorders

• Hyperthyroidism • Thyroid tumors

• Hypothyroidism Follicular carcinoma
• Goiter (single nodular or Papillary carcinoma
Multinodular) Medullary carcinoma
Anaplastic carcinoma

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Pre operative assessment.
1. Focused anesthetic history thus;
i. Chief complain, example pain on the throat.
ii. History of presenting illness.
iii. Past medical history.
iv. Past anesthetic and surgical history.
v. Current medical history , example DM,HT.
vi. Allergies.
vii. Social and family history.

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2. Focused physical examination
i. General examination , thus include all the vital signs .
ii. Airway assessment, a) LEMON b) BONES.
Symptoms of dysphagia, positional breathlessness,
stridor may alert the anaesthetist to possible difficulties with
airway compromise on induction

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3. Focused investigations.
i. Fully blood count.
ii. CT-Scan
iii. Chest x-ray.
iv. Serum electrolytes.
v. Thyroid function test.
vi. Nasendoscopy.(diagnostic procedure used for examination of the nose,
throat and airway)
vii. Lateral thoracic inlet x-ray (plain radiography is requested to investigate the
presence of soft tissue swellings in the neck and the upper thorax and to
demonstrate the effects on the air passages E.g, the presence of retrosternal
goitre)
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The normal thyroid function test

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4. Optimization.
• For elective surgeries ; hyperthyroidism
Antithyroid drugs should be given at least from 6-8 weeks prior
surgery for euthyroid state. Example methimazole.
Iodide –inhibit release of thyroid hormone.
Beta blockers. Example propranolol.
Avoid anticholinergic drugs(may produce tachycardia).
Intensive airway examination for any problem like laryngeal
compression or laryngeal nerve involvement.

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Cont…
• For emergency surgery; hyperthyroidism.
Use Iv beta blockers (esmolol), ipodate(iodinate contrast),
glucocorticoids(decrease hormone release and reduce peripheral
conversion of T4 to T3).
Be prepared to manage thyroid storm.

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Cont…
• For elective surgeries; hypothyroidism.
Treat hypodynamic CV system (decrease CO, SV, HR, IV volume)
-Treat hypotension with ephedrine, dopamine, or epinephrine and not
pure alpha agonist(phenylephrine).
Decrease ventilator response to hypoxia/hypercarbia.
-utilize controlled ventilation.
Increase sensitivity to anaesthetics by giving opioids/IV anaesthetics,
and myocardial depressant effects of potent inhaled agents but don’t
change MAC.
Treat other risk like hypothermia, hyponatremia, hypoglycemia.
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Cont…
• For emergence surgery ; hypothyroidism.
Give IV T3 effective in 6hours.
Give steroids; Hydrocortisone or dexamethasone coverage
- due to decreased adrenal cortical function often accompanies
hypothyroidism.
If symptomatic /unstable coronary artery disease(CAD) present ,you
must weigh risks of precipitating myocardial ischemia with thyroid
replacement.

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Intraoperative.
Anesthesia techniques.
1.Regional anesthesia.
• Bilateral deep or superficial cervical plexus blocks is used.
• Regional anesthesia can be safely given in hyperthyroidism cases,
however local anesthetic with adrenaline must not be used.
• In hypothyroidism cases, coagulation abnormality and platelets
dysfunction should be ruled out first.

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Complications of regional….
• Vascular puncture.
• Peripheral nerve injury.
• Systemic toxicity.

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2.General anesthesia.
Intubation technique.

• Unexpected difficult intubation.

Item which should be available do deal with such a situation include;
Various sizes of tracheal tubes.
Gum elastic bougies.
A levering laryngoscope.
Straight-bladed laryngoscope.
LMA.

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Cont…
• The trachea is intubated using the convectional laryngoscopy. A
reinforced tube should be considered.
• North polar oral tracheal tube should be used as an alternative as
they keep the respiratory filter away from the surgical field.
• Nasal tracheal tube can also be used.
• It is wise to select a small reinforced tracheal tube if there is any
degree of tracheal compression.

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Expected difficult intubation.
• Awake fibreoptic intubation technique.
• LMA can be used with spontaneous respiration and intermittent
positive pressure ventilation.
• However relative contraindication of using LMA include tracheal
narrowing or deviation.
• Also, there is a risk that LMA will be displaced during surgery and
laryngospasm occurs in relation to surgical manipulation.

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Armoured tracheal tube=Has reinforced metal coils which make
it less likely to get obstructed(Has a wire embedded in the wall)

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North polar tracheal tube

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Awake fibreoptic intubation.

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Hyperthyroidism.
• Induction: As sodium thiopentone posses antithyroid properties
therefore , it can be induction drug of choice.
• Maintenance: As hyperthyroid patient are more prone to arrhythmias
therefore, most cardiac stable drug such as isoflurane should be
preferred agent.
-Minimum alveolar concentration (MAC) of inhalation agents should
remain the same throughout in hyperthyroidism.
• Muscle relaxant: Vecuronium being most cardiac stable is most
preferred.

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Hypothyroidism.
• Induction: Normally is done with propofol however, if there is
evidence of low cardiac output then ketamine is preferred.
• Maintenance: Isoflurane because of its cardiac stability hence most
preferred.
• Muscle relaxant: As mivacurium, atracurium/cis-atracurium do not
have the possibilities of accumulation hence, preferred muscle
relaxant.

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Postoperative care
• Residual neuromuscular block is reversed and the patient is allowed
to recover from anesthesia.
• Any concern during dissection of the recurrent laryngeal nerve , the
vocal cords are checked and the surgeon is reassured.
• A fibreoptic endoscope may be used to view the vocal cords
automatically.
• When adequate spontaneous respiration and laryngeal reflexes have
returned, the patient is extubated.
• Every attempt should be done to prevent coughing.

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Cont…
• If there is no immediate respiratory obstruction, the patient is
transferred to the recovery ward.
• The patient is carefully observed for the development of a cervical
hematoma and is returned to the ward after attaining appropriate
discharge criteria.
• Signs of hypocalcemia are treated with calcium supplements and,
following thyroidectomy, thyroxine 100uq daily is prescribed.
• Postoperatively, vocal cord function is examined by indirect
laryngoscopy before discharge.

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The complications
1. Parathyroid Injury.
• Acute hypocalcemia which occurs within 24-48 hours in 3-5% patient
after surgery.
• Symptoms – laryngeal stridor/spasm, tingling lips/fingertips, carpopedal
spasm(trousseau’s sign).
• Treatment – intravenous calcium, airway management( CPAP, intubation)

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Cont…
2. Neck Hematoma.
• Signs of swelling or hematoma formation that’s compromising the
patient airway should be decompressed by removal of surgical clips
3. Thyroid storm.
• Life threatening exacerbation of hyperthyroidism. Occurs 6-8 hours
after post operatively( but can occur intraoperatively).
• Symptoms – hyperthermia ,extreme tachycardia, high CO, altered
mental state, dehydration, hyperglycemia, shock, death.
• Differential diagnosis- malignant hyperthermia, sepsis,
pheochromocytoma, amphetamine overdose.

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 Cont..
NOTE;- MH vs Thyroid storm
• Sustained tarchycardia, hyperthermia, increased oxygen consumption
shared by both.
• MH only; increased EtCO2 and arterial PaCO2, muscle rigidity.

Management .
• Corrected whatever is precipitating, treat the vital signs.
• Give beta blockers(esmolol)
• Iv fluid(usually glucose containing crystalloids) for volume replacement.
• Cooling measures, acetaminophen.
• Antithyroid drugs example, propylthiouracil (PTU)
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Cont…
4. Myxedema Coma.
• Rare severe form of hypothyroidism .
• Medical emergency ; Mortality level is approximately 50%.
• Presentations;- stupor or coma , hypoventilation , hypothermia(as low as 27C) it’s a
cardinal feature with impaired thermoregulations , bradycardia , hypotension , severe
dilutional hyponatremia.

Treatment
• IV T3 (faster onset) or IV T4.
• Steroids (hydrocortisone 100-300mg iv/day) to treat possible adrenal insufficiency.
• Vital signs stabilization.

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SUMMARY

• Perioperative airway complications are common and the expected or

unexpected difficult airway should be anticipated.
• Patients should be clinically and chemically euthyroid prior to thyroid
surgery.
• Postoperative complications of haematoma formation, recurrent
laryngeal nerve palsy, hypocalcaemia and tracheomalacia (collapse of
the airway when breathing) can all cause airway compromise and
must be acted upon quickly.

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References.
• Kumar P, Clark M. Clinical medicine 4th ed. W. B Saunders 1999. 932-941
• Farling P.A. Thyroid disease. British Journal of Anaesthesia 2000;
85(1):15-28
• Malhotra S, Sodhi V. Anaesthesia for thyroid and parathyroid
surgery. Continuing Education in Anaesthesia Critical Care and Pain 2007;
7(2): 55-58
• Spanknebel K, Chabot JA, DiGeorgi M, Cheung K, Lee S, Allendorf J,
LoGerfo P. Thyroidectomy Using Local Anaesthesia: A Report of 1,025
Cases over 16 Years. Journal of American College of
Surgeons 2005;201(3): 375-385

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