PRINCIPLE OF NURSING CARE AND

MANAGEMENT OF PATIENT WITH

HYPERTHYROIDISM
PERIOPERATIVE MANAGEMENT.

Presenter: Emmanuel Odiwel Mbalwa

Facilitator: Dr Hakolo.

NOVEMBER 2023
OBJECTIVES

• Definition.
• Understand risk of providing anaesthesia.
• Preoperative assessment.
• Preoperative investigation and optimization
• Intraoperative anaesthesia management
• Mode of anaethesia
• Postoperative care of pt with hyperthyroidism.
INTRODUCTION

• Hyperthyroidism is hyperactivity of the thyroid gland with sustained

increase in synthesis and release of thyroid hormones.
• THYROTOXICOSIS refers to physiological effect or clinical syndrome
of hypermetabolism that result from excess circulating levels of T4,T3 or
both.
• Hyperthyrodism and thyrotoxicosis usually occur in graves’ disease.
• Graves’ disease- an autoimmune disease of unknown etiology marked
by diffuse thyroid enlargement and excessive thyroid hormone
secretion.
PERIOPERATIVE MANAGEMENT

Preoperative assessment
• Airway
• Marked tracheal deviation or compression
• Stridor/respiratory distress on supine position
• Assess vocal cord movement (to recognize pre
existing laryngeal nerve palsy)- Nasendoscopy
 PERIOPERATIVE MANAGEMENT

• Eyes
• Lid retraction and Exophthalmos (must be protected from
intraoperative trauma)
• Cardiovascular
• Hyperthyroidism (Tachycardia, AF and Heart failure)
• Large goiter (Obstruct venous drainage)
• Retrosternal goiter (SVC compression)
PERIOPERATIVE

A. Preoperative management
• Investigations
• Thyroid function test (TSH, T3, T4)
• Serum electrolytes (Ca, Mg, PO3-)
• CXR & Thoracic inlet view ( to assess airway
compression or deviation)
PERIOP MX CONT…
INVETIGATIONS CONT..
• CT scan & MRI (to delineate the degree and extent
of airway narrowing with retrosternal goiter or
severe stridor)
• Blood Urea Nitrogen
• Complete blood count
• ECG and ECHO (if appropriate)
• Nasendoscopy (performed preoperatively by ENT to
document vocal cord function).
ANAESTHETIC CONSIDERATIONS

Optimization
• Elective surgery should be postponed until the patient is
euthyroid with medical treatment
• Antithyroid medications should be administered until the
day of surgery except for Carbimazole as it increases the
vascularity of the gland.
• Esmolol infusion is useful in emergency setting with
hyperthyroidism to relieve the symptoms
• Benzodiazepines may be administered for anxiolysis but
should be avoided if there is any airway concern
• Anticholinergics may be helpful to dry secretions if an
inhalational or fibre-optic technique is planned.
• For optimal surgical access the head is fully extended
and rested on a padded ring with a sandbag between the
scapulae.
PERIOP CONT…………..

B. Intraoperative management
• Usual medications with ASA standard monitoring but…
• Avoid sympathetic activating drugs like Ketamine
• Adequate anesthesia depth before laryngoscopy or
surgical stimulation is highly recommended (to avoid
Tachycardia, HTN and ventricular arrhythmias)
PERIOP ………………….

• Neuromuscular blocking agents should be administered with

caution in thyrotoxicosis (due increased risk of MG and
Myopathies)
• Supplementation of Beta blocker may be necessary as
manipulation of the gland releases more hormones
• Monitor cardiovascular and temperature (↑ Temperature
susp…Thyroid storm)
• Protect eyes from corneal abrasion in exophthalmos
PERIOP………………..
Options in increased airway concerns
1. Induction in the semi-supine or sitting position
2. Inhalation induction with sevoflurane- (Sevo in Heliox in severe
stridor) and maintain with inhalational agent or Remifentanil iv
3. Fibreoptic intubation in severe laryngeal displacement or airway
problems
4. Tracheostomy under local anesthetic may be performed by the surgeon.
5. Ventilation through a rigid bronchoscope if ETT attempt fails e.g. in
mid-lower tracheal obstruction
PERIOP……….

Muscle relaxants use in increased airway concern

1. It is possible to perform tracheal intubation without MR with
experienced hands
2. Succinylcholine is an ideal agent owing to its rapid onset and
shorter duration but avoided due to undesirable side effects
like dysrhythmias
3. Rocuronium 1.2mg/kg is used to achieve swift onset of
optimal intubating conditions, neuromuscular blocking effect
may be rapidly terminated by Sugammadex16mg/kg.
PERIOP

C. Post operative management

• Smooth emergency/Fully awake with spont. breathing
• Close monitoring for post operative complications
• Post operative analgesia (LA, weak opioids, PCM)
• Antiemetics (Ondansetron+Dexamethasone)-retching may
increase rule out hematoma
• Resolution of thyrotoxicosis is expected after 7 days post
thyroidectomy (Half life for T4 is 7 days)
PERIOP………..

• Hematoma
• Urgent evacuation and homeostasis is needed
• Life long hypothyroidism (iodine deficiency)
• Requires life long supplementation
• Pneumothorax
• Following extensive and difficult retrosternal
resection
SUMMARY

• Thyroidectomy is commonly performed surgery and gained popularity

since middle 19th C ranges simple to complex surgery.
• Patients should be clinically and chemically euthyroid prior to thyroid
surgery.
• Roles of anesthesia to thyroidectomy include preoperative assessment
and optimization, anticipated difficult airway, adequate surgical
relaxation and postoperative urgent airway complications.
• Thyroid storm although less common than it used to be, is a medical
emergency (active cooling, hydration, beta blockers and antithyroid
drugs).
REFERENCES

• Clinical Anaesthesiology, 5th edition,2015.Morgan &Mikhail’s

• IJA: Anesthesia and thyroid surgery: The never ending
challenges by Sukhminder J
• Anesthesia for thyroid surgery-WFSA
• Chen AY,Bernet VJ Cart SE,et al. American thyroid
Association statement on optimal surgical management of
goiter.thyroid 2014;24:186.
Comments…
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