THYROIDECTOMY

Question 1

Thyroidectomy Procedure
6 DSA TRW
Types of resection
What does resection begin with 
Avoid  injury to 
SIT LGF

Answer 1

6-8 cm transverse neck incision at the base the neck. Division of the platysma muscle.
Subplatysmal flaps are then developed superiorly and inferiorly to expose the thyroid.
A spring or self-retaining retractor may be placed to expose the midline fascia.

(Thyroid gland exposed, resection can begin. Resection may be total, subtotal (lobe, isthmus, + partial remaining lobe), or lobar.
**(Resection typically begins with the ligation and division of vessels, such as the middle thyroid vein on the
midlateral side of the thyroid,
**(While also carefully voiding injury to the EXTERNAL BRANCH OF SUPERIOR LARYNGEAL NERVE

superior pole of the thyroid is then freed by controlling and dividing the superior thyroid vessels while staying close to the thyroid capsule to avoid injury to the external branch of the superior laryngeal
nerve.
As dissection continues, the surgeon tries to Identify and preserve the superior and inferior parathyroid glands.
The lobe is medially retracted to visualize the recurrent laryngeal nerve, which is traced along its entire course
The **gland is then gently dissected away from the nerve and taken off the trachea. .Lastly, the **fascia and muscles are sutured closed the skin is closed.

Question 2

To confirm nerve function

Answer 2

A nerve monitor may be used to confirm nerve function.

Question 3

Hemostasis checked by

Answer 3

performing a Valsalva maneuver before closure.

Question 4

Enlarged lymph nodes are

Answer 4

sent to pathology

Question 5

Drain placement

Answer 5

is controversial.

Question 6

Position—Supine =

Answer 6

Supine, HOB 30 degrees, neck extended. Arms are padded and tucked.

Question 7

Supine hemodynamic changes:

Answer 7

↓ HR ↓ SVR, increased right-sided filling
and C.O. from increased blood return and BP is equalized. Supine can ↓ FRC ~ 800cc due to cephalad displacement of diaphragm
compressing the lungs.

Question 8

Supine hemodynamic changes:

Answer 8

↓ HR ↓ SVR, increased right-sided filling and C.O. from increased blood return and BP is equalized. Supine can ↓ FRC ~ 800cc due to cephalad displacement of diaphragm
compressing the lungs.

Question 9

CV—resting HR =.

Answer 9

60-85

Question 10

Hyperthyroidism S/S

Answer 10

increased HR, atrial fib, palpitations, and CHF. Patient may need beta blockers if emergent surgery; caution use with CHF.

Question 11

Hyperthyroidism Thyroid storm = life threatening, s/s =

Answer 11

hyperthermia, tachycardia, widened pulse pressure, anxiety, neuro changes, ( maybe mistaken malignant hyperthermia.

Question 12

With hypothyroidism,=

Answer 12

bradydysrhythmias, diastolic HTN or dysfunction, pericardial effusions, and ECG changes (ST wave changes, increased QT interval, and torsades de
pointe). Caution volume expansion if ↓ LV compliance.

Question 13

RESPIRATORY WITH THYROIDECTOMY: HYPERTHYROIDISM

Answer 13

Respiratory—with hyperthyroid, increases in basal metabolic rate (BMR) increases oxygen consumption leading to rapid desaturation on induction.
Goiters can compress the trachea = deviation, stridor,
and ↓ ventilatory response to increased CO2 and ↓ O2. Prepare for a difficult airway and be cautious using opioids /sedatives.

Question 14

HYPOTHYROIDISM RESPIRATORY

Answer 14

Also, patients with untreated hypothyroid may have gastroparesis and could be at risk for aspiration.

Question 15

Neuro— DTR

Answer 15

check positioning and eyes.
Consider eye padding for exophthalmos.
Add padding to prevent nerve injury. Hyperthyroid may have tremors and INCREASED deep tendon reflexes. may require generous sedation for nervousness and anxiety.

Question 16

NEURO Hypothyroid patients will have

Answer 16

↓BMR leading to slow mentation and movement, cold intolerance, and ↓ reflexes.

Question 17

deficit: May be

Answer 17

dehydrated and need volume repletion. use goal directed therapy, NS/LR 5-8 mL/kg/hr.
EBL: minimal blood loss
expected; However, risk significant blood loss

Question 18

PREOP Thyroidecomey

Answer 18

Preop— 18g IV bleeding. Type & cross. Ideal to be euthyroid, stable, check temperature, HR, pulse pressure, and reflexes. Assess for
s/s of thyrotoxicosis due to increased risk of morbidity. Thyroid stimulating hormone (TSH) should be normal before surgery. ALINE

Question 19

Intraop— GETA ETT type.

Answer 19

Armored ETT may be useful for this procedure, but typically NIM (neural integrity monitor) ETT is used if usingintraoperative neuromonitoring (IONM).
requires direct contact of electrodes with cords. A grounding wire will usually be pierced through skin in the shoulder or arm.

Question 20

Check with surgeon regarding the

Answer 20

use of muscle paralytics and nerve monitoring. Paralytic should not be used if nerve monitoring is in use.

Question 21

Succ and N2)

Answer 21

Anectine may be given with RSI. Nitrous oxide may be given as well.

Question 22

if relaxants

Answer 22

If relaxants are used, avoid histamine releasing drugs.

Question 23

If airway is deviated or compressed and/or affected by a large gland

Answer 23

consider awake FOB. Use caution using sedation if compromised airway.

Question 24

Less commonly,

Answer 24

regional anesthesia may be an anesthetic approach for this procedure using bilateral deep cervical plexus blocks and IV sedation.

Question 25

may not be beneficial for hyperthyroid pts.

Answer 25

epi with LA

Question 26

Additionally, have _______ available for hyperthyroid pts in case of SNS response

Answer 26

beta blockers

Question 27

Hyperthyroid patients “ Avoid drugs that stimulate SNS such a

Answer 27

ketamine, meperidine, pancuronium, etc.)

Question 28

_________may be useful in these cases due to the

Answer 28

Controlled hypotension; vascularity of the neck,

Question 29

Keep SBP ______ and MAP Vasopressors to support BP.

Answer 29

<100 mmHg; 60-65.

Question 30

Stimulation of the trachea can cause

Answer 30

the patient to cough /buck, so if muscle relaxants are not in use, deepened anesthesia.

Question 31

smoothen the anesthetic effect.

Answer 31

Propofol

Question 32

The electrodes sense EMG (electromyographic) activity from the

Answer 32

THYROARYTENOID muscles and when the surgeon stimulates the RLN using a probe attached to the monitor, an audible alert will be heard and even visual.

Question 33

Emergence—

Answer 33

monitor for edema and swelling (leak test). Be aware of airway obstruction from possible recurrent laryngeal nerve injury, tracheomalacia, or hematoma.

Question 34

Extubation Consider

Answer 34

Consider visualizing vocal cord function before extubating. Smooth emergence is essential.

Question 35

Emergence Avoid

Answer 35

patient straining or coughing/gagging = bleeding and swelling at site.

Question 36

Deeper stages of anesthesia are usually required to

Answer 36

blunt laryngo-tracheal responses

Question 37

Blung laryngo-tracheal responses with

Answer 37

=Low-dose remifentanil infusion 0.08–1.0 mcg/kg/min. Multimodal antiemetic prophylaxis for PONV.

Question 38

Recurrent laryngeal nerve damage—bilateral,

Coughing/PONV =stress on suture line bleeding or hematoma = intervention

Answer 38

not be able to speak and will require reintubation. Unilateral = hoarseness. SLN
injury = voice changes as well.

Question 39

=Tracheomalacia or hematoma with airway compromise—

Answer 39

acute obstruction may occur immediately
postop and will require rapid reintubation. Hematoma will require re-exploration and drainage. Consider CPAP or awake reintubation.

Question 40

Acute hypoparathyroid state (hypocalcemia)–

Answer 40

monitor for s/s of hypocalcemia =laryngeal stridor (24-48hr postop), tingling in the fingers or lips, and Chvostek’s or Trousseau’s sign. Tx: calcium gluconate, CPAP.

Question 41

Post op issues

Answer 41

Hypocalcemia
Coughing PONV
Pneumothorax
Upper airway Edema
Hypothyroidsim

Question 42

Pain

Answer 42

PCA/ oral meds

Question 43

Assess for hematoma if s/s AMS =

Answer 43

compromised airway and oxygenation.