Parathyroidectomy

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
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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,

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.

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
• Reverse Trendelenburg or 30 degree HOB elevation
• Head in Gel donut

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.

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

	Open	Minimally invasive (endoscopic)	Minimally invasive (robotic)
Unique considerations
Position	Supine; shoulder roll; reverse Trendelenberg, headrest with gel donut
Surgical time	1-2h
EBL	25-50mL
Postoperative disposition	PACU to either med surg for Ca monitoring x 24 hours, or PACU to home
Pain management	3-4	Less than open	less than open
Potential complications	Hypocalcemia: <15% Hypoparathyroidism: <5% Hematoma: 1% Infection: 1% Recurrent laryngeal paralysis: <1%