anaesthetic aspects of thyroid and parathyroid … of anaesthesia for thyroid and parathyroid...
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Anaesthetic Aspects of Thyroid and Parathyroid Surgery
Mireille Berthoud
2014
Thyroid disease
Reasons why patients may come to surgery
• Grave’s Disease
• Thyroid nodule
• Thyroid cancer
• Multinodular goitre
• Other more rare conditions
Parathyroid disease
Reasons why patients may come to surgery
• Primary parathyroid disease
• Tertiary parathyroid disease
Physiology of thyroid hormones Hypothalamus
TRH
Pituitary Gland TSH
Thyroid Gland FT4 FT3
Peripheral Tissues T4 T3
T4 and T3
T4 and T3
-
- +
+
What is meant by subclinical disease?
Serum TSH High Low
Hypothyroidism ? Hyperthyroidism?
Free T4 and Free T3 Free T4 and Free T3
High Low Normal Normal
Sub-clinical Hypothyroidism
Sub-clinical Hyperthyroidism
Hypothyroidism Hyperthyroidism
The normal for TSH is 0.27 to 4.2 mIU/l, for adults in STH
Grave’s disease
What is it?
• Autoimmune thyroiditis
• Immunoglobulins cause false TSH
stimulation
• Diffuse goitre
• Associated eye disease
• 8x more common in women
• Up to 2% of the population
Grave’s disease
What treatments are available? Why operate?
• Medical management
• Radioiodine
• Surgical management – Less relapse
– Airway obstruction
– Thyroid eye disease
– Pregnancy
– Patient choice
Euthyroid for surgery
• Anti-thyroid drugs
Carbimazole
Propylthiouracil
• B blockers
• Lugol’s iodine
• Steroids
Famous folk with thyroid eye disease
Thyrotoxic crisis
• I have never seen it
• Saba has seen it twice, in a medical context
• Peri-operative crises are rare now days
• Diagnosis is clinical
• Needs to be managed on ITU, with respiratory and CVS support available.
Thyrotoxic crisis: Treatment
• Treat electrolyte imbalance (iv glucose is useful as patient has a hypermetabolic state)
• Treat hypercalcaemia
• Treat arrhythmias (B blockers, e.g. Esmolol, propranalol for IV)
• Control hyperthermia (dantroline)
• Correct hyperthyroid sate (propylthiouracil, Leugol’s iodine, glucocorticoids)
• Plasmapheresis
Thyroid nodules and thyroid cancer
• 10% of patients who have surgically removed thyroid nodules return to theatre for completion thyroidectomy
• Thyroid cancer is increasing in incidence
• It (mostly) carries an excellent prognosis, depending on the type
• Surgery for cancer is more complex, takes longer and is more prone to RLN damage
• Difficult airways occur more frequently in thyroid cancer patients, than from goitres of other causes
Types of thyroid cancer
• Papillary cancer: (78%) 10 year survival of 90%. Spreads locally and to the lymph nodes. May invade the trachea.
• Follicular cancer: (17%) More aggressive than papillary, but still 80% 10 year survival. Spreads to lungs, bone liver and brain. Metastasis concentrate radio iodine.
• Medullary cancer: (4%) 5 year survival is 80%. Sporadic or familial when it is associated with MEN 2A and 2B.
• Anaplastic cancer: very poor prognosis. Surgery usually only palliative.
Monitoring the recurrent laryngeal nerve.
• Some centres do this for all thyroid operations.
• In Sheffield we do it in patients with cancer, in patients having recurrent surgery, and in patients where we already know one of the nerves is damaged.
• It involves a special endotracheal tube with electrodes in contact with the vocal cords, and an anaesthetic technique without muscle relaxation.
Red to Right
The difficult airway
• All patients should be intubated, preferably with an armoured ET.
• All patients should have indirect laryngoscopy to assess cord function pre-op.
• In practice most elective patients are straight forward, even with quite narrowed or deviated tracheas, if not cancer. Size of goitre is not predictive.
• The books quote 6% of cases are difficult. Anaplastic cancer is the worst.
• The warning signs are just the same for any potential obstructed airway: dysphagia, stridor, dyspnoea when lying flat, choking.
The difficult airway
• In my time, we have never employed flow volume loops in Sheffield.
• Imaging is very helpful, but symptoms are more important.
• The method of choice for most papers is an awake fibre-optic intubation, and a small armoured ET though the nose.
• Gas induction is still an option. • Tracheostomy may not be possible because of the
overlying tumour. • Case reports for extra-corporial oxygenation in the
literature all start with intubated patients.
The difficult airway
Multinodular goitre
• The most common reason for operating on patients with a multinodular goitre is to relieve or prevent obstructive symptoms.
• Cosmesis may be a reason for surgery.
• They can be toxic or hypothyroid
• They can have a difficult airway, though this is less common than in thyroid cancer, even for big goitres, and quite narrowed tracheas.
Retro-sternal goitre
Primary Hyperparathyroidism
Symptoms of hyperparathyroidism
ORGAN SYSTEM SYMPTOM/SIGN
Skeletal, articular Osteopenia, gout and pseudo gout
Neuropsychiatric Depression, anxiety, lethargy, fatigueability
Cardiovascular Hypertension, vascular calcification
Gastroentestinal Peptic ulcer disease, pancreatitis, impaired glucose tollerance
Renal Stones of all types, 30% have a reduced GFR.
Haematological Anaemia
Primary Hyperparathyroidism
• Pre-op preparation is to optimise the general medical condition of the patient.
• Avoid thiazides and lithium.
• Control the hypercalcaemia. In practice Martin and I will not be too anxious in any patient with a corrected calcium at or below 3mmol/mol.
Medical Treatment of Hypercalcaemia
• Only hope for cure is surgery
• Correction of vitamin D deficiency
• Do not dehydrate
• Acutely, fluids and sometimes loop diuretics
• Biphosphonates (don’t lower calcium)
• Calcimimetics
Finding the adenoma.
• Pre-operatively
– Ultrasound
– CT/MRI
– Radionuclide isotope scanning
• Focal surgery
Finding the adenoma.
• Per-operatively
– Methylene blue
– Gamma probe
– Intra-operative PTH
– Frozen section
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retchingDVT prophylaxis • DVT prophylaxis
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Bilateral superficial cervical blocks
Images for the New York School of Regional Anaesthesia web site at http://www.nysora.com
Bilateral superficial cervical blocks
Conduct of anaesthesia for thyroid and parathyroid surgery
• Need to protect the airway • Need to minimise bleeding • Need to provide good positioning for surgical access • May need un-paralysed patient • May be a long procedure • Need to allow for haemostasis at the end of the
surgery • Need smooth emergence • Need good post-operative analgesia and to minimise
coughing and straining and retching • DVT prophylaxis
Postoperative complications • Haematoma
• Recurrent Laryngeal Nerve Damage
• Tracheomalacia
• Laryngeal oedema
• Hypocalcaemia