Difference between revisions of "Thyroidectomy"
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5-lead ECG | 5-lead ECG | ||
Neuromonitoring | Neuromonitoring | ||
| considerations_preoperative = | | considerations_preoperative = Potential for tracheal compression, deviation due to mass effect creating difficult airway | ||
| considerations_intraoperative = | | considerations_intraoperative = Avoiding paralytic due to RLN monitoring | ||
| considerations_postoperative = | | considerations_postoperative = Hypocalcemia | ||
Recurrent laryngeal nerve palsy | |||
}} | }} | ||
A '''thyroidectomy''' is a procedure used to treat patients with hyperthyroidism that has not responded to conservative medical treatment. Procedure can involve the removal of the entire thyroid gland (total thyroidectomy), removal of 1 lobe (thyroid lobectomy, or hemithyroidectomy), or some variation. The procedure is usually done as an open thyroidectomy, though a minimally invasive transoral thyroidectomy can also be performed. | A '''thyroidectomy''' is a procedure used to treat patients with hyperthyroidism that has not responded to conservative medical treatment. Procedure can involve the removal of the entire thyroid gland (total thyroidectomy), removal of 1 lobe (thyroid lobectomy, or hemithyroidectomy), or some variation. The procedure is usually done as an open thyroidectomy, though a minimally invasive transoral thyroidectomy can also be performed. | ||
| Line 22: | Line 22: | ||
|- | |- | ||
|Airway | |Airway | ||
| | |Large goiter can compress airway or cause vocal cord paralysis | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| Line 28: | Line 28: | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Tachycardia, tachyarrhythmias | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| Line 43: | Line 43: | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Thyroid storm | ||
|- | |- | ||
|Other | |Other | ||
| Line 50: | Line 50: | ||
=== 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. --> === | ||
* Thyroid studies | |||
* BMP | |||
=== 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. --> === | ||
* NIM tube for intraop vocal cord nerve stimulation | |||
* Video scope for NIM tube placement | |||
=== 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. --> === | ||
N/A | |||
=== 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. --> === | ||
* Surgeon may be able to infiltrate the site with local | |||
== 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. --> === | ||
* Standard ASA monitors | |||
* IONM (intra operative nerve monitoring) for 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. --> === | ||
* NIM endotracheal tube (for neuro monitoring) | |||
* Video laryngoscope for surgeons to ensure proper electrode placement | |||
*Succinylcholine or remifentanil bolus (up to 4 mcg/kg) for intubating conditions | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine | |||
*ENT surgeons tend to rotate the bed 90 or 180 degrees. Surgical oncologists tend to avoid rotating. | |||
=== 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 paralysis for nerve monitoring | |||
* Consider remifentanil instead of paralytic agents, (0.05-0.2mcg/kg/min typically throughout the case) | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* Avoid bucking/coughing as this can lead to neck hematoma | |||
** Consider deep extubation | |||
** Consider leaving remifentanil on (~0.05 mcg/kg/min) until extubation | |||
== 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. --> === | ||
* PACU, stay in hospital | |||
=== 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. --> === | ||
* Pain is worse with minimally invasive transoral approach. | |||
* Usually can be managed with Tylenol and oral opioids in PACU, can consider IV opioids as backup | |||
=== 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. --> === | ||
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* 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 | * Recurrent laryngeal nerve injury, if unilateral, results in a hoarse voice, but if bilateral, can result in obstructed airway requiring emergent tracheostomy | ||
*Hypocalcemia | |||
== 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). --> == | ||
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|+ | |+ | ||
! | ! | ||
! | !Open thyroidectomy | ||
! | !Transoral thyroidectomy (minimally invasive) | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | | | ||
| | | | ||
|- | |- | ||
|Position | |Position | ||
| Line 109: | Line 141: | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |Pain is less significant | ||
| | |Pain is worse, consider giving long acting opioid during the case | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
Latest revision as of 19:27, 26 June 2024
Thyroidectomy
| Anesthesia type |
General |
|---|---|
| Airway |
Neuromonitoring ETT |
| Lines and access |
PIV |
| Monitors |
Standard 5-lead ECG Neuromonitoring |
| Primary anesthetic considerations | |
| Preoperative |
Potential for tracheal compression, deviation due to mass effect creating difficult airway |
| Intraoperative |
Avoiding paralytic due to RLN monitoring |
| Postoperative |
Hypocalcemia Recurrent laryngeal nerve palsy |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A thyroidectomy is a procedure used to treat patients with hyperthyroidism that has not responded to conservative medical treatment. Procedure can involve the removal of the entire thyroid gland (total thyroidectomy), removal of 1 lobe (thyroid lobectomy, or hemithyroidectomy), or some variation. The procedure is usually done as an open thyroidectomy, though a minimally invasive transoral thyroidectomy can also be performed.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | Large goiter can compress airway or cause vocal cord paralysis |
| Neurologic | |
| Cardiovascular | Tachycardia, tachyarrhythmias |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | Thyroid storm |
| Other |
Labs and studies
- Thyroid studies
- BMP
Operating room setup
- NIM tube for intraop vocal cord nerve stimulation
- Video scope for NIM tube placement
Patient preparation and premedication
N/A
Regional and neuraxial techniques
- Surgeon may be able to infiltrate the site with local
Intraoperative management
Monitoring and access
- Standard ASA monitors
- IONM (intra operative nerve monitoring) for recurrent laryngeal nerve
Induction and airway management
- NIM endotracheal tube (for neuro monitoring)
- Video laryngoscope for surgeons to ensure proper electrode placement
- Succinylcholine or remifentanil bolus (up to 4 mcg/kg) for intubating conditions
Positioning
- Supine
- ENT surgeons tend to rotate the bed 90 or 180 degrees. Surgical oncologists tend to avoid rotating.
Maintenance and surgical considerations
- Avoid paralysis for nerve monitoring
- Consider remifentanil instead of paralytic agents, (0.05-0.2mcg/kg/min typically throughout the case)
Emergence
- Avoid bucking/coughing as this can lead to neck hematoma
- Consider deep extubation
- Consider leaving remifentanil on (~0.05 mcg/kg/min) until extubation
Postoperative management
Disposition
- PACU, stay in hospital
Pain management
- Pain is worse with minimally invasive transoral approach.
- Usually can be managed with Tylenol and oral opioids in PACU, can consider IV opioids as backup
Potential complications
- 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
- Hypocalcemia
Procedure variants
| Open thyroidectomy | Transoral thyroidectomy (minimally invasive) | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | Pain is less significant | Pain is worse, consider giving long acting opioid during the case |
| Potential complications |
References
Top contributors: Tony Wang, Olivia Sutton and Chris Rishel