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 = Hypocalcemia | | considerations_postoperative = Hypocalcemia | ||
Recurrent laryngeal nerve palsy | Recurrent laryngeal nerve palsy | ||
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=== 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. --> === | ||
| Line 60: | Line 63: | ||
=== 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 == | ||
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=== 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 | * 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 | * 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 | * Avoid paralysis for nerve monitoring | ||
* Consider remifentanil instead | * 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 | * Avoid bucking/coughing as this can lead to neck hematoma | ||
** Consider deep extubation | ** Consider deep extubation | ||
** Consider leaving | ** Consider leaving remifentanil on (~0.05 mcg/kg/min) until extubation | ||
== Postoperative management == | == Postoperative management == | ||
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=== 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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|+ | |+ | ||
! | ! | ||
! | !Open thyroidectomy | ||
! | !Transoral thyroidectomy (minimally invasive) | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | | | ||
| | | | ||
|- | |- | ||
|Position | |Position | ||
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|- | |- | ||
|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