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Case 65. Thyroidectomy in Patient with Hypertension. A 38 year old man is scheduled for thyroid goiter surgery. He has a history of hypertension and has been on metaproterenol and captopril. BP: 180/110, PR: 80/min ECG no specific ST-T changes. Preoperative Evaluation.

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thyroidectomy in patient with hypertension

Case 65

Thyroidectomy in Patient with Hypertension

A 38 year old man is scheduled for thyroid goiter surgery. He has a history of hypertension and has been on metaproterenol and captopril. BP: 180/110, PR: 80/min ECG no specific ST-T changes.

preoperative evaluation
Preoperative Evaluation
  • History: symptoms of hyperthyroidism such as anxiety, fatigue, heat intolerance, diarrhea, dyspnea, and palpitations
  • PE: BP, T, HR(tachycardia?), rhythym(tachydysrhythmias?), goiter, Thyrotoxic myopathy(proximal weakness), exophthalmos
  • PMH: Hypertension, asthma
preop labs tests
Preop/Labs/Tests
  • TSH, T3, T4
    • Is patient euthyroid?
  • CBC, LFT, ECG
  • CT neck, flow-volume loops
    • Airway obstruction?
preop medication
Preop Medication
  • Clonidine
    • Will blunt sympathetic nervous response
  • Midazolam
  • No anticholinergics
    • Interfere with heat regulation and contribute to increased heart rate
induction anesthesia muscle relaxants
Induction Anesthesia/Muscle Relaxants
  • Thiopental
    • Thiourea structure with antithyroid activity
  • NDNM or succinyl choline
alternate intubation plan
Alternate Intubation Plan
  • Awake intubation with fentanyl
maintenance anesthetic agents
Maintenance Anesthetic Agents
  • Sevoflurane/nitrous oxide mixture
    • Suppresses sympathetic nervous system
  • Possibly avoid Desflurane
    • Large bolus can cause transient increase in sympathetic activity
  • Alternate is short-acting opioid/nitrous oxide
    • However, does not reliably suppress sympathetic nervous system.
intraoperative medical care
Intraoperative Medical Care
  • Thyroid storm, which mimics malignant hyperthermia, can consist of hyperthermia, tachycardia, CHF, low intravascular volume, and shock
    • Chilled crystalloid infusion
    • Continuous esmolol infusion
    • Propylthiouracil, methimazole, NaI
    • If persistent hypotension, then Dexamethasone
      • Inhibits T4 to T3 conversion
    • No aspirin
      • Increases level of free T4
  • Elevated BP
    • Esmolol
early postoperative care
Early Postoperative Care
  • Thyroid storm usually occurs 6-18 hrs post-op
  • Other Complication:
    • Recurrent laryngeal nerve injury
    • Hematoma
    • Tracheomalacia
    • Hypoparathyroidism
    • Superior laryngeal nerve injury
  • Pain management - PCA