THYROIDECTOMY Flashcards
Thyroidectomy Procedure 6 DSA TRW Types of resection What does resection begin with Avoid injury to SIT LGF
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.
To confirm nerve function
A nerve monitor may be used to confirm nerve function.
Hemostasis checked by
performing a Valsalva maneuver before closure.
Enlarged lymph nodes are
sent to pathology
Drain placement
is controversial.
Position—Supine =
Supine, HOB 30 degrees, neck extended. Arms are padded and tucked.
Supine hemodynamic changes:
↓ 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.
Supine hemodynamic changes:
↓ 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.
CV—resting HR =.
60-85
Hyperthyroidism S/S
increased HR, atrial fib, palpitations, and CHF. Patient may need beta blockers if emergent surgery; caution use with CHF.
Hyperthyroidism Thyroid storm = life threatening, s/s =
hyperthermia, tachycardia, widened pulse pressure, anxiety, neuro changes, ( maybe mistaken malignant hyperthermia.
With hypothyroidism,=
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.
RESPIRATORY WITH THYROIDECTOMY: HYPERTHYROIDISM
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.
HYPOTHYROIDISM RESPIRATORY
Also, patients with untreated hypothyroid may have gastroparesis and could be at risk for aspiration.
Neuro— DTR
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.
NEURO Hypothyroid patients will have
↓BMR leading to slow mentation and movement, cold intolerance, and ↓ reflexes.
deficit: May be
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
PREOP Thyroidecomey
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
Intraop— GETA ETT type.
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.
Check with surgeon regarding the
use of muscle paralytics and nerve monitoring. Paralytic should not be used if nerve monitoring is in use.
Succ and N2)
Anectine may be given with RSI. Nitrous oxide may be given as well.
if relaxants
If relaxants are used, avoid histamine releasing drugs.
If airway is deviated or compressed and/or affected by a large gland
consider awake FOB. Use caution using sedation if compromised airway.
Less commonly,
regional anesthesia may be an anesthetic approach for this procedure using bilateral deep cervical plexus blocks and IV sedation.
may not be beneficial for hyperthyroid pts.
epi with LA
Additionally, have _______ available for hyperthyroid pts in case of SNS response
beta blockers
Hyperthyroid patients “ Avoid drugs that stimulate SNS such a
ketamine, meperidine, pancuronium, etc.)
_________may be useful in these cases due to the
Controlled hypotension; vascularity of the neck,
Keep SBP ______ and MAP Vasopressors to support BP.
<100 mmHg; 60-65.
Stimulation of the trachea can cause
the patient to cough /buck, so if muscle relaxants are not in use, deepened anesthesia.
smoothen the anesthetic effect.
Propofol
The electrodes sense EMG (electromyographic) activity from the
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.
Emergence—
monitor for edema and swelling (leak test). Be aware of airway obstruction from possible recurrent laryngeal nerve injury, tracheomalacia, or hematoma.
Extubation Consider
Consider visualizing vocal cord function before extubating. Smooth emergence is essential.
Emergence Avoid
patient straining or coughing/gagging = bleeding and swelling at site.
Deeper stages of anesthesia are usually required to
blunt laryngo-tracheal responses
Blung laryngo-tracheal responses with
=Low-dose remifentanil infusion 0.08–1.0 mcg/kg/min. Multimodal antiemetic prophylaxis for PONV.
Recurrent laryngeal nerve damage—bilateral,
Coughing/PONV =stress on suture line bleeding or hematoma = intervention
not be able to speak and will require reintubation. Unilateral = hoarseness. SLN
injury = voice changes as well.
=Tracheomalacia or hematoma with airway compromise—
acute obstruction may occur immediately
postop and will require rapid reintubation. Hematoma will require re-exploration and drainage. Consider CPAP or awake reintubation.
Acute hypoparathyroid state (hypocalcemia)–
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.
Post op issues
Hypocalcemia Coughing PONV Pneumothorax Upper airway Edema Hypothyroidsim
Pain
PCA/ oral meds
Assess for hematoma if s/s AMS =
compromised airway and oxygenation.
