Thyroidectomy

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
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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