Parathyroidectomy

From WikiAnesthesia
Parathyroidectomy
Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative


Normal human physiology consists of four parathyroid glands. A parathyroidectomy is the removal of one or more of these 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
Respiratory 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

Positioning

  • Supine
  • Shoulder roll

Maintenance and surgical considerations

Emergence

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