Chris bowen t4 keyword presentation april 29th 2011 anesthesia
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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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Thyroid Storm

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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


Thank you

Thank You


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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