Difference between revisions of "Parathyroidectomy"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = Neuromonitoring ETT | ||
| lines_access = | | lines_access = PIV | ||
| monitors = | | monitors = Standard | ||
5-lead ECG | |||
Temperature | |||
Neuromonitoring | |||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = | | considerations_intraoperative = Relaxation with remifentanil if neuro monitoring | ||
| considerations_postoperative = | | considerations_postoperative = Hypocalcemia | ||
}} | Recurrent laryngeal nerve palsy | ||
}}A '''parathyroidectomy''' is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies. | |||
==Preoperative management == | |||
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | |||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
!System | ! System | ||
!Considerations | !Considerations | ||
|- | |- | ||
| Line 25: | Line 27: | ||
|Hypertension and tachycardia are common | |Hypertension and tachycardia are common | ||
|- | |- | ||
| | |Pulmonary | ||
|Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin) | |Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin) | ||
|- | |- | ||
|Gastrointestinal | | Gastrointestinal | ||
|Hypercalcemia can cause constipation, nausea/vomiting | |Hypercalcemia can cause constipation, nausea/vomiting | ||
|- | |- | ||
| Line 44: | Line 46: | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* EKG | *EKG | ||
* CBC | *CBC | ||
* BMP to evaluate calcium, magnesium, phosphate, | *BMP to evaluate calcium, magnesium, phosphate, | ||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->=== | ||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
Patients should receive IV fluids and diuresis to control calcium levels. | Patients should receive IV fluids and diuresis to control calcium levels. | ||
Radioactive tracers such as methylene blue or technetium Sestamibi may be administered preoperatively to facilitate detection of parathyroid glands intraoperatively. | Radioactive tracers such as methylene blue or technetium Sestamibi may be administered preoperatively to facilitate detection of parathyroid glands intraoperatively. | ||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
== Intraoperative management == | ==Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ||
* Intraoperative nerve monitoring (IONM) is used by surgeon to avoid injury to recurrent laryngeal nerve | *Intraoperative nerve monitoring (IONM) is used by surgeon to avoid injury to recurrent laryngeal nerve | ||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
* NIMS endotracheal tube is used for recurrent laryngeal nerve monitoring | |||
* Preferably use video laryngoscope so surgery team can confirm lead placement | |||
* Supine | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
*Supine | |||
* Shoulder roll | * Shoulder roll | ||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
*Avoid paralytic for nerve monitoring. Consider remifentanil instead. | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | |||
* Ensure smooth emergence with minimal coughing/bucking, as this can cause neck bleeding | |||
** Consider leaving remifentanil on (around 0.05 mcg/kg/min) or extubating deep. | |||
== Postoperative management == | ==Postoperative management== | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
Regular calcium levels to evaluate for postoperative hypocalcemia, which can occur in up to 15% of patients. | Regular calcium levels to evaluate for postoperative hypocalcemia, which can occur in up to 15% of patients. | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Symptomatic hypocalcemia | * Symptomatic hypocalcemia | ||
* Neck hematoma is rare but can develop rapidly, resulting airway compromise. Thus it is a surgical emergency requiring prompt takeback. | *Neck hematoma is rare but can develop rapidly, resulting airway compromise. Thus it is a surgical emergency requiring prompt takeback. | ||
* | *Recurrent laryngeal nerve injury, if unilateral, results in a hoarse voice, but if bilateral, can result in obstructed airway requiring emergent tracheostomy | ||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
! | ! | ||
!Variant 1 | ! Variant 1 | ||
!Variant 2 | !Variant 2 | ||
|- | |- | ||
| Line 128: | Line 136: | ||
|} | |} | ||
== References == | ==References== | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
[[Category:General surgery]] | |||
[[Category:Endocrine surgery]] | |||
Latest revision as of 06:42, 29 June 2022
Parathyroidectomy
| Anesthesia type |
General |
|---|---|
| Airway |
Neuromonitoring ETT |
| Lines and access |
PIV |
| Monitors |
Standard 5-lead ECG Temperature Neuromonitoring |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
Relaxation with remifentanil if neuro monitoring |
| Postoperative |
Hypocalcemia Recurrent laryngeal nerve palsy |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A parathyroidectomy is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | Hypercalcemia can cause altered mental status, weakness, myalgia, and rarely seizures |
| Cardiovascular | Hypertension and tachycardia are common |
| Pulmonary | Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin) |
| Gastrointestinal | Hypercalcemia can cause constipation, nausea/vomiting |
| Hematologic | |
| Renal | Hypercalcemia can cause polyuria/polydipsia resulting in other electrolyte abnormalities. Also increased risk for nephrolithiasis |
| Endocrine | |
| Other |
Labs and studies
- EKG
- CBC
- BMP to evaluate calcium, magnesium, phosphate,
Operating room setup
Patient preparation and premedication
Patients should receive IV fluids and diuresis to control calcium levels.
Radioactive tracers such as methylene blue or technetium Sestamibi may be administered preoperatively to facilitate detection of parathyroid glands intraoperatively.
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
- Intraoperative nerve monitoring (IONM) is used by surgeon to avoid injury to recurrent laryngeal nerve
Induction and airway management
- NIMS endotracheal tube is used for recurrent laryngeal nerve monitoring
- Preferably use video laryngoscope so surgery team can confirm lead placement
Positioning
- Supine
- Shoulder roll
Maintenance and surgical considerations
- Avoid paralytic for nerve monitoring. Consider remifentanil instead.
Emergence
- Ensure smooth emergence with minimal coughing/bucking, as this can cause neck bleeding
- Consider leaving remifentanil on (around 0.05 mcg/kg/min) or extubating deep.
Postoperative management
Disposition
Regular calcium levels to evaluate for postoperative hypocalcemia, which can occur in up to 15% of patients.
Pain management
Potential complications
- Symptomatic hypocalcemia
- Neck hematoma is rare but can develop rapidly, resulting airway compromise. Thus it is a surgical emergency requiring prompt takeback.
- Recurrent laryngeal nerve injury, if unilateral, results in a hoarse voice, but if bilateral, can result in obstructed airway requiring emergent tracheostomy
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
Top contributors: Tony Wang and Chris Rishel