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Chris Bowen T4 Keyword Presentation April 29th 2011 Anesthesia. Thyroid Storm. Your 6 AM is ready. 44 y/o patient with Graves’ Dx Recently cleared for total thyroidectomy The surgical H&P: AF VSS WNL RRR no m/r/g CTAB. Upon exam. Vitals: 101.9 167 153/86 26 Agitation

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chris bowen t4 keyword presentation april 29th 2011 anesthesia
Chris Bowen T4

Keyword Presentation

April 29th 2011

Anesthesia

Thyroid Storm

your 6 am is ready
Your 6 AM is ready
  • 44 y/o patient with Graves’ Dx
  • Recently cleared for total thyroidectomy
  • The surgical H&P:
    • AF VSS WNL RRR no m/r/g CTAB
upon exam
Upon exam
  • Vitals: 101.9 167 153/86 26
  • Agitation
  • Scleralicterus
  • Bilateral crackles with expiratory wheezing
  • Palpitations
  • Mild diaphoresis and nausea without emesis
  • No obstruction of airway 2 /2 goiter
thyroid storm
Thyroid Storm
  • Thyrotoxic vs. Thyroid Storm
  • Life-threatening complication
    • Mortality with Tx 8% or below
  • Most cases occur post-op
    • Within 6-18 hrs
    • Why? Pre-op Tx necessary?
  • Si/Sx varied but consider…
    • Hyperdynamic Metabolism
  • SITT DD are common triggers
  • Burch and Wartofsky Score
    • ≥ 45 highly suggestive of thyroid storm
    • ≤ 25 thyroid storm unlikely
burch and wartofsky point system
Burch and wartofskypoint system
  • Temp:
    • 99-99.9 5 points
    • 100-100.9 10 points
    • ≥ 104.0 30 points
  • Tachycardia
    • 90-109 5 points
    • 110-119 10 points
    • 120-129 15 points
    • ≥140 25 points
  • A. Fib
    • Absent 0 points
    • Present 10 points
  • Precipitating Event
    • Absent 0 points
    • Present 10 points
  • CHF
    • Absent 0 points
    • Mild (pedal edema) 5 points
    • Moderate (bb rales) 10 points
    • Severe(pulm edema) 15 points
  • CNS
    • Absent 0 points
    • Mild 10 points
    • Moderate 20 points
    • Severe 30 points
  • GI-Hepatic
    • Absent 0 points
    • Moderate 10 points
    • Severe 20 points
management
Management
  • Pre-op euthyroidism
    • Goiter?
    • Patients with tachycardia and HTN  consider cancellation
  • Iodide
    • Sodium Iodide, Iopanoic acid, Lugol’s solution
      • Block the release of hormone
      • Wolff-Chaikoff effect
  • Beta-Blocker
  • Cortisol
    • Adrenal function?
  • Thionamides
    • PTU favored for decrease in peripheral conversion
  • Cholestyramine
  • Temp control
  • Hydration
    • With or without glucose?
post op complications
Post-op complications
  • Nerve damage
    • Superior Laryngeal
      • Motor to Cricothyroid mm.  aspiration
    • Recurrent Laryngeal
      • Everything laryngeal except Cricothyroid  Hoarseness, stridor, total airway obstruction
  • Hypoparathyroidism
    • Laryngospasm
  • Hypothyroidism
  • Tracheal Compression
references
References
  • “Big Blue”
  • Nayak B., Burman K.: Thyrotoxicosis and Thyroid Storm. Endocrinology and Metabolism Clinics 35. (4): 2006.
  • Pearce E., Braverman L.: Hyperthyroidism: advantages and disadvantages of medical therapy. Surgical Clinics of North America 84. (3): 2004.
  • Franklyn JA.: The Management of Hyperthyroidism. New England Journal of Medicine 330 (24): 1731-8. 1994 abstract.
  • Burch H.B., Wartofsky L.: Life-threatening thyrotoxicosis. Thyroid Storm. Endocrinology and Metabolism Clinics of North America 22: 263-277. 1993. abstract.
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