UBP 3.7 (Long Form): Endocrine – Thyroidectomy Flashcards
Secondary Subject -- Bipolar Disorder – Lithium/Flow Volume Loops/ Difficult Airway/Thyroid Storm/ MH/ Neuroleptic Malignant Syndrome/Recurrent Laryngeal Nerve Injury/Hypocalcemia
Intra-operative Management:
What monitors would you place for this case?
Are invasive monitors warranted?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
In addition to the standard ASA monitors, I would place
a 5-lead EKG to monitor for myocardial ischemia as well as place an esophageal or bladder probe to monitor core temperature.
Recognizing the potential for lithium-induced conduction-problems or dysrhythmias, and given the increased perioperative risks associated with inadequately treated hyperthyroidism, such as a hyperdynamic circulation, cardiac arrhythmias, and thyroid storm, I would place an arterial line to aid in monitoring and timely treatment of hemodynamic instability
(these patient often exhibit an exaggerated sympathetic response to surgery).
Considering her treatment with lithium (long term use may result in a form of vasopressin resistant diabetes insipidus), her questionable volume status (hyperthyroid state may result in hypovolemia), and the length of the case, I would place a Foley catheter.
Finally, since the duration of action of muscle relaxants may be prolonged in patients receiving lithium, I would carefully monitor neuromuscular blockade with a peripheral nerve stimulator.
Intra-operative Management:
How would you induce anesthesia?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
Given her hyperthyroidism, airway obstruction, and GERD, my goals during induction would be to safely secure the airway while maintaining spontaneous respirations, maintaining stable hemodynamics, and avoiding aspiration.
Therefore, I would administer an H2-receptor antagonist and metoclopramide; and ensure the presence of difficult airway equipment, a rigid bronchoscope, reinforced endotracheal tubes in various sizes, a tracheostomy kit, and a surgeon capable of performing an emergency tracheostomy.
I would then verify sufficient B-blockade, ensure adequate airway analgesia, and provide minimal sedation to prevent an exaggerated sympathetic response during intubation, recognizing that the latter two interventions could theoretically increase the risk of aspiration and exacerbate airway obstruction.
Finally, I would place the patient in slightly reverse trendelenburg position and perform an awake fiberoptic intubation, passing a reinforced endotracheal tube beyond the point of extrinsic compression.
Intra-operative Management:
How would you anesthetize the airway?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
While maintaining spontaneous ventilation, I would provide minimal sedation and supplemental oxygen; administer nebulized lidocaine to anesthetize the oropharynx (above the epiglottis); topicalize the nose in case a nasal airway becomes necessary; and block the superior laryngeal nerves to anesthetize the hypopharynx (below the epiglottis to the vocal cords).
While a trans-tracheal block may aid in anesthetizing the larynx (below the vocal cords), it may NOT be an appropriate airway block for a patient with goiter.
Moreover, when anesthetizing the airway, I would AVOID epinephrine-containing local anesthetics to reduce the risk of an exaggerated hemodynamic response with systemic absorption.
http://www.pitt.edu/~regional/Airway%20Blocks/airway_blocks.htm
Inhalational Local Anesthetic Technique: – Refer to last link on this flash card… for safety info on this technique. According to Reference article #14 – relatively safe.
Intra-operative Management:
The patient refuses an awake intubation.
What are you going to do?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
I would make the patient, her family, and the surgeon aware of my concerns of possible difficult intubation, mask ventilation, and complete airway obstruction.
At the same time, I would attempt to identify and address the patient’s concerns with an awake intubation, reassuring her that all steps would be taken to make sure the procedure as comfortable as possible.
If she still refused this procedure, I would administer an H2-receptor antagonist and metoclopramide; and
ensure the presence of difficult airway equipment, a rigid bronchoscope, reinforced endotracheal tubes in various sizes, a tracheostomy kit, and a surgeon capable of performing an emergency tracheostomy.
I would then have the neck prepped and draped, place the patient in slight reverse trendelenburg position, apply cricoid pressure, provide minimal sedation, and perform an inhalational induction with sevoflurane with the goal of maintaining spontaneous respiration until the airway is secured.
Finally, I would pass a reinforced endotracheal tube, ensuring that the distal tip of the tube extends beyond the point of extrinsic compression.
Intra-operative Management:
How would you maintain anesthesia?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
I would maintain anesthesia with a balanced technique consisting of IV narcotics and a volatile anesthetic, being careful to maintain an adequate depth of anesthesia to prevent exaggerated sympathetic responses to surgical stimulation.
Additionally, I would AVOID the administration of any agents that stimulate the central nervous system, such as – atropine, ketamine, desflurane, ephedrine, epinephrine, and pancuronium.
If intraoperative hypotension occurred, I would treat with fluids and a direct-acting vasopressor such as phenylephrine.
(LOOK UP AND REVIEW – See Stoelting Co-Existing Dz)
Given the increased incidence of myasthenia gravis in hyperthyroid patients, any administration of muscle relaxants would begin with a reduced initial dose, with subsequent dosing carefully titrated based on responses from a peripheral nerve stimulator (also keep in mind the potential for prolonged blockade secondary to lithium treatment).
Finally, I would take extra precautions to protect the patient’s eyes (especially if there was evidence of proptosis) and
closely monitor the patient for any signs of thyroid storm, such as – hyperthermia, dysrhythmias, tachycardia, myocardial ischemia, congestive heart failure, and cardiovascular instability.
Intra-operative Management:
How does thyrotoxicosis affect minimum alveolar concentration (MAC)?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
There is no objective data to support the impression that hyperthyroidism has any direct effect on MAC.
However, the increased cardiac output associated with thyrotoxicosis would theoretically increase the uptake of inhaled anesthetics.
This increased uptake would slow the rate of rise of FA/FI (fraction alveolar/fraction inspired), which could potentially be perceived as an increased anesthetic requirement.
In addition, increases in core body temperature often associated with thyrotoxicosis could potentially increase MAC.
Intra-operative Management:
How would you extubate this patient at the end of the case?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
While any preoperative mass-induced airway compression should be resolved following total thyroidectomy, the patient remains at risk for post-extubation airway obstruction secondary to –
tracheomalacia, hematoma, edema, or recurrent laryngeal nerve injury.
Moreover, this hyperthyroid patient with GERD is at increased risk of aspiration and an exaggerated sympathetic response during emergence.
Given these concerns, I would ensure the presence of difficult airway equipment; plan to extubate the patient when she was awake and demonstrating intact airway reflexes; administer B-blockers, narcotics, and lidocaine as necessary to blunt a sympathetic response; pass a fiberoptic bronchoscope through the endotracheal tube, and slowly pull the tube back while, at the same time, visualizing the patency of the airway and vocal cord movement.
If at any time the airway appeared to be compromised, I would immediately re-advance the ETT.
Intra-operative Management:
What would you expect to find with a recurrent laryngeal nerve injury?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
Acute injury to the abductor fibers of the recurrent laryngeal nerve is one of the most concerning complications associated with thyroidectomy.
While a rare occurrence, bilateral injury results in unopposed adduction of the true vocal cords, resulting in stridor, aphonia, and laryngeal obstruction.
This type of injury requires intubation to maintain airway patency.
Unilateral injury is more common, characterized by hoarseness, and does not result in laryngeal obstruction due to compensatory abduction of the unaffected vocal cord.
Post-operative Management:
Assume extubation was uneventful.
Three hours after surgery the patient develops inspiratory stridor, restlessness, and tingling around her mouth.
What is your differential diagnosis?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
Stridor associated with restlessness and circumoral tingling or numbness is consistent with hypocalcemia, a known complication of total thyroidectomy secondary to inadvertent surgical removal of the parathyroid glands.
While this complication typically develops 24-96 hours after surgery, it may manifest in as early as 1 to 3 hours.
However, I would also consider – cervical hematoma formation, post-intubation croup, residual neuromuscular blockade (higher incidence of myasthenia gravis in hyperthyroid patients), recurrent laryngeal nerve injury, hypoglycemia, hypoxia, or hypercapnia.
Post-operative Management:
Assume extubation was uneventful.
Three hours after surgery the patient develops inspiratory stridor, restlessness, and tingling around her mouth.
What would you do?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
I would evaluate the patient; provide supplemental oxygen; auscultate the chest; ensure stable hemodynamics; adequate ventilation, and a normal cardiac rhythm; examine the patient’s neck for signs of hematoma formation; attempt to illicit Chvostek sign (twitching of the facial muscles with tapping of the facial nerve at the angle of the jaw) or Trousseau sign (spasm of the hand muscles with occlusion of the brachial artery for three minutes using an inflated sphygmomanometer); examine the patient for hyperactive tendon reflexes; check an arterial blood gas, electrolytes, and serum phosphate concentration; and consider ordering a chest x-ray.
If I believed her respiratory distress was secondary to hypocalcemia, I would administer intravenous calcium (rule of 10s: 10 mL of 10% calcium gluconate over 10 minutes), correct any hyperkalemia and/or hypomagnesemia (these potentiate hypocalcemia-induced cardiac and neuromuscular irritability), and continue to monitor the EKG for signs of cardiotoxicity (i.e. ventricular fibrillation, heart block).
If, however, I believed her respiratory distress was due to hematoma-induced compression of the trachea, I would evacuate the hematoma, intubate the patient (airway edema secondary to hematoma-induced inhibition of venous and lymphatic drainage may persist even after hematoma evacuation), administer steroids and nebulized racemic epinephrine to decrease laryngeal edema, and sit the patient upright to facilitate venous drainage.
Finally, if I believed that bilateral recurrent laryngeal nerve injury was the causative factor, I would immediately secure the airway with an endotracheal tube and notify the surgeon (who may consider tracheotomy).
Post-operative Management:
Six hours after surgery the nurse calls you and reports the patient is tachycardiac and febrile with a temp of 38.9ºC.
She wants to administer aspirin as an anti-pyretic. Do you agree?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
I am concerned that her symptoms could potentially represent thyroid storm.
Therefore, I would NOT administer aspirin to this patient because this drug may displace thyroid hormones from binding proteins in the blood, subsequently increasing free thyroid hormone levels and potentially exacerbating her condition.
Instead, I would assess the patient, administer acetaminophen, ensure stable hemodynamics, and attempt to identify the underlying cause of her symptoms.
Given this patient’s hyperthyroid state, lack of anesthetic history, and recent olanzapine dosage adjustment, her symptoms could potentially represent thyroid storm, malignant hyperthermia, and neuroleptic malignant syndrome, respectively.
Other potential causes that I would consider, include light anesthesia and an undiagnosed pheochromocytoma.
Post-operative Management:
How would you differentiate between thyroid storm, malignant hyperthermia (MH), and neuroleptic malignant syndrome (NMS)?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
Differentiating between these various conditions would be very difficult in this patient with risk factors for all three conditions, especially since they all manifest similarly with tachycardia, hyperthermia, and mental status changes.
However, both malignant hyperthermia and neuroleptic malignant syndrome result in – a metabolic acidosis, profound hypercarbia, and muscle rigidity, symptoms NOT present during thyroid storm.
Distinguishing between NMS and MH would be even more difficult in this patient who has received a triggering agent and is receiving medications that can lead to dopamine depletion.
Two distinguishing features are:
- NMS usually exhibits a slower progression to a critical temperature and multisystem organ failure as compared to MH;
- non-depolarizing muscle relaxants will produce flaccid paralysis in patients experiencing NMS, but NOT in those experiencing MH.
Unfortunately, treatment should be initiated immediately, making an observation of the speed of progression less helpful.
Therefore, in a situation where I was unable to readily determine whether MH or NMS was the cause of a patient’s hypermetabolic state, I would initate treatment with dantrolene, which may prove helpful with both conditions (occasionally used as adjunctive treatment of NMS);
intubate the patient following the administration of a non-triggering induction agent and a nondepolarizing muscle relaxant; hyperventilate the patient with 100% oxygen; consider administering bromocriptine (a dopamine agonist often used in the treatment of NMS), if the nondepolarizing agent results in the resolution of muscle rigidity; initiate cooling measures; and continue with the appropriate monitoring and supportive care.
Post-operative Management:
Assuming this was a case of thyroid storm how would you treat this patient?
- (A 21-year-old female is scheduled for a total thyroidectomy for a multinodular goiter. She states she has had progressive dyspnea and dysphagia over the last 2 weeks.*
- PMHx: Hyperthyroidism, GERD, Irritable bowel syndrome, Bipolar disorder – her olanzapine dosage was recently adjusted*
- Anesth. Hx: None*
- Meds: lithium, propylthiouracil, olanzapine, and oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: HR = 122, BP = 158/88 mmHg, RR = 22, Temp = 37.6 ºC, Weight 56 kg, 159 cm*
- Airway: Mallampati II, full cervical range of motion*
- Cardiovascular: regular rate and rhythm*
- Pulmonary: inspiratory stridor, lungs clear*
- Labs: Hgb = 13 mg/dl, TSH = 0.2 mU/L (0.3-3.0 mU/L), Free T4 = 3.0 ng/dL (0.7-1.0 ng/dL), T3 = 280 µg/dL (80-180 ng/dL)*
- Pregnancy Test: Negative*
- CT: Large thyroid mass resulting in tracheal compression and deviation)*
I would treat thyroid storm by administering acetaminophen and initiating active cooling measures (i.e. cold lavage, cooling blankets, ice packs, etc.) to control hyperthermia;
titrating on additional B-blocker to control tachycardia (esmolol or propranolol);
provide intravenous fluids to ensure adequate intravascular fluid volume;
correct any electrolyte imbalance; and
administer propylthiouracil, sodium iodide, and hydrocortisone to reduce circulating levels of active thyroid hormone.
If necessary, I would consider administering a catecholamine-depleting agent, such as reserpine or guanethidine, to aid in treating hyperadrenergic effects of thyroid storm.
(Look up this last point…)
