Hyperthyroidism

Co-existing diseases: The

Endocrine System

Boston Medical Center

Dept. of Anesthesiology
Gerardo Rodriguez, MD

Outline

Case sample
Medical disease background
Preoperative evaluation & preparation
Intraoperative management
Postoperative management
Highlight airway issues.

Case Sample
62y.o. Albania female w/ goiter x 20yrs,
moved to U.S. 4mos ago. Refused surgery,
very anxious. Now w/ worsening SOB when
supine and dysphagia.
PMhx: HTN, Afib, Thyroid storm?
PEx:
VS: T98.7, 160/80, 113, 20, 100% RA
Airway: MP2
HEENT: Large goiter

CT imaging: R-deviated trachea w/o

compression.

Background
Hyperthyroidism is a condition caused by the effects
of too much thyroid hormone.
Hyperthyroidism: usu. excess synthesis and
secretion of thyroid hormone by the thyroid gland,
also known as thyrotoxicosis.
free thyroxine (T4), free triiodothyronine (T3), or both.

Most common of thyrotoxicosis:

diffuse toxic goiter (Graves disease, ~50-60%)
toxic multinodular goiter (Plummer disease, 15-20%)
toxic adenoma (3-5%).

Epidemiology
U.S.

Graves
Annual incidence: ~0.5 cases in 1000 persons.
Peak age occurrence: 20-40yrs.
diffuse toxic goiter (Graves disease, ~50-60%)
toxic multinodular goiter (Plummer disease, 15-20%)
toxic adenoma (3-5%).

International
Frequency of Graves and toxic multinodular goiter vary by
iodide intake.
E.g. US has I- intake incid of Graves > toxic goiter

Epidemiology

http://www.scielosp.org/scielo.php

Epidemiology
Gender
Women>men (Graves, female-to-male: 1 to 5-10.)

Age
Graves: 20-40yrs
Toxic multinodular goiter: >50yrs

Race
Graves: Caucasians/Asians/Hispanics >> Black population

Evaluating Hoarseness: Keeping Your Patient's Voice Healthy - June 1998 - American
Academy of Family Physicians; http://www.aafp.org/afp/980600ap/rosen.html

Evaluating Hoarseness: Keeping Your Patient's Voice Healthy - June 1998 - American
Academy of Family Physicians; http://www.aafp.org/afp/980600ap/rosen.html

Review the laryngeal

innervation.

Evaluating Hoarseness: Keeping Your Patient's Voice Healthy - June 1998 - American
Academy of Family Physicians; http://www.aafp.org/afp/980600ap/rosen.html

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TIFF (LZW) deco mpressor
are neede d to se e this picture.

www.medscape.com; http://ae.medseek.com/

T3 / T4

T3 ~10x more potent than T4:

T3
T4
Peak Onset
24hrs
10 days
Effect Lasts
2-3 days 2-3
weeks

Mitochondrial effects:

mRNA transcription

Na-K-ATPase synthesis

BMR

Cellular energy use:

GLC absorption

Glycolysis

Gluconeogenesis

Insulin secretion

Cellular-GLC uptake

Lipolysis

Lipids metabolism

Chol to bile serum Chol/

TG/PL.

[Thyroid hormone] oxidative phosphorylation

uncoupling (i.e. short circuits the coupling between the electron
transport chain and ATP synthesis) heat production/
inefficient energy conversion.

HR, contractility CO
O2 consumption, CO2
production Vt, RR

/ PTH levels
bone turnover (i.e.
formation/ catabolism)

Vasodilation
Blood flow

Systems Signs/Sx

Constitutional
Sweating, warm/moist skin, muscle weakness, wt
loss, appetite

CV
HR, high-output CHF, cardiomegaly,
pulm/periph edema, MVP, Afib, heart block,
dysrhythmias

Resistant to digitalis/ cardiac glycosides.

apathetic (i.e. blunted signs/sx) hyperthyroidism in pts
age>60, cardiac manifestations predominate, e.g AFib.

Pulm
RR, min vent

Systems Signs/Sx

Neuro
Anxiety, confusion, tremor, seizures

GI
Secretory diarrhea, alk phos

Heme
Wbc, Hb, Plts

Renal
K excretion, Na excretion.

Systems Signs/Sx

Ocular

Derm

Exophthalmus
Vitiligo, hyperpigmentation.

Psych

Emotional instability, insomnia

Thyroid storm
Acute, severe, exacerbation of thyrotoxicosis due to
acute serum T3/T4.
Causes: stressors
DKA, infection, acute I- tx withdrawal, trauma, thyroid gland
manipulation, radioactive I-, surgery, ether anesthesia.

Onset: sudden. For surgical pts at risk, it may occur:

Intraop
Postop: 6-18hrs.

Signs
T, HR, CHF, confusion, Glc, shock, death.

Preoperative Preparation
Medical Therapy: Thyrotoxicosis
Goal: euthyroid. Resting HR best sign of acceptable tx.
Traditional pre-op tx: Antithyroid meds >2 mos before
surgery, then may be stopped post-op.
Propylthiouracil or methimazole
Saturated KI sol
Li-carbonate (if I- allergy)

More recent preop tx: Treat x 7-14days w/

Saturated KI sol
Propanolol or nadolol: -blockers postop >7days.

Preoperative Preparation
Medical Therapy: Thyroid storm
Immediate tx
Cooled IV fluids
Propylthiouracil: T4 synthesis + peripheral T4-to-T3
conversion
Methimazole (PO/NG)

Followup tx
Propylthiouracil (PO Q8)
Na I- (IV Q8)
Saturated KI sol (PO QD): T4 synth/secretion (Wolf-Chaikoff
effect)
Propanolol (IV, max 10mg, titrate to HR<90, then PO)
Hydrocortisone (IV Q8)

Preoperative Preparation
Airway assessment tools
CXR/ CT imaging
Tracheal deviation?
Airway obstruction/ compression?

Pulmonary Function Testing (PFT)

Non-invasive
Flow-volume loops

Preoperative Preparation
Normal Flow-Volume Loop
Used to eval airway
obstruction.
Can determine the extent +
location of airway
obstruction.
Intrathoracic (variable)
Extrathoracic (variable)
Fixed

Preoperative Preparation
How to produce a FlowVolume Loop?
(1): Inhale to TLC.
(1 to 2): Exhale to RV.
(2 to 3): Inhale to TLC.

How might loops

change w/ various
obstructions?
2

Anesthetic Management
A review of cases performed at the University of
California, San Francisco, from 1968 to 1982 revealed
that virtually all anesthetic drugs and techniques have
been used without adverse effects even being
remotely attributable to the drug or technique.
Roizen MF, Becker CE: Thyroid storm: A review of cases at University of California, San Francisco. Calif Med
115:5, 1971.

No controlled study has demonstrated clinical

advantages of any anesthetic drug over another for
surgical patients who are hyperthyroid.
Millers Anesthesia, 6th Ed.; www.anesthesiatext.com

Anesthetic Management
Preinduction preparation:
Airway obstruction assessment
Airway exam: Large Goiter/ airway obstruction
Difficult Airway?
CXR/ CT imaging
PFTs

Airway devices: difficult intubation cart?, AFOI?,

re-inforced ETT?
Premeds: minimize sedation?

Anesthetic Management
Intraoperative management:
GA/Induction:
Thiopental: antithyroid activity.
Ketamine: avoid, sympath activity.
Muscle relaxants: avoid agents w/ cardiac effects.
Maintenance:
MAC requirement
narcotics?: to blunt sympath stim.
Muscle relaxants: caution, possible prolonged effects if preop muscle
weakness.
PaCO2: avoid, sympath stim.
Temp monitoring
Exophthalmus: corneal injury susceptibility.

Anesthetic Management
Postoperative management:
Monitor for postop complications:
Tracheomalacia
Thyroid storm
Bilateral recurrent laryngeal nerve injury
Unopposed ad-duction of vocal cords: stridor,
aphonia, airway obstruction.
Unopposed ab-duction of vocal cords: aspiration risk.

Hypocalcemic tetany
Postop Hematoma