Thyroid Gland and Anesthetic Management

Daniel Stairs CRNA, MSN, MBA Excela Health School of Anesthesia

Thyroid Gland is H-shaped Right and left lobe with isthmus

Location of Thyroid Gland

Anterior to trachea Just below cricoid cartilage Covering second through fourth tracheal rings Thyroid gland weighs about 20 gm

Blood Supply to Thyroid Gland

4 to 6 cc/min/gm Arterial supply via inferior and superior arteries Venous supply via inferior, middle, and superior thyroid veins

Nerve Supply
Two

superior laryngeal nerves and two recurrent laryngeal nerves supply the entire sensory and motor innervations to the larynx.

Innervation

Recurrent Laryngeal Nerve

Most common nerve injured in throidectomy Motor supply Sensation below vocal cords With selective injury to abductor fibers: (1) hoarseness (2) bilateral injury (3) obstruction

Recurrent Laryngeal Nerve

Selective injury to adduction fibers Post-operative assessment after thyroidectomy is via laryngoscopy and having patient phonate letter e Most common nerve injury

Superior Laryngeal Nerve

Motor supply to cricothyroid muscle (SLN external branch) Internal branch provides sensation above the vocal cords Injury causes possible risk for aspiration and hoarseness

Essential Thyroid Hormones

Thyroxine or T4 Triiodothyronine or T3 Release of these hormones into circulation stimulated by TSH T3 is less firmly bound to carrier proteins and disappears from circulation quicker T3 is 3-5 times as potent as T4 but is limited by its transient nature

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Thyroid Hormones
Nearly all circulating T3 is derived from peripheral conversion of T4 Major Functions of Thyroid Hormones: (1) calorigenic effects (2) growth and cellular differentiation (3) metabolic effects (4) muscular effects

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Other Functions of Thyroid Hormones

Working with growth hormone, they ensure proper development of the brain Increase protein breakdown and glucose uptake by cells, enhance glycogenolysis. and depress cholesterol levels In excess they may interfere with ATP synthesis and thus speed the exhaustion of energy in muscle tissues

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Thyroid Hormones
Thyroxine normal serum range is 5-12 mcg/dL Triiodothyronine normal serum range is 70-90 ng/dL

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Laboratory Testing of Thyroid Hormone

(1)
(2) (3) (4) (5)

Five General Categories Direct tests of thyroid function Tests relating to the concentration and binding of thyroid hormones in blood Metabolic indexes Tests of homeostatic control of thyroid function Miscellaneous tests
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(1) Direct Tests

In-vivo administration of radioactive iodine Thyroid Radioactive Iodine Uptake (RAIU) is the most common RAIU is measured 24 hours after administration of isotope Normal is 10-30% of administered dose after 24 hours Values above normal indicate thyroid hyperfunction
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(2) Tests Related to Hormone Concentration and Binding

Are radioimmunoassays Highly specific and sensitive radioimmunoassays to measure serum T3 and T4 Highly sensitive TSH assay is the most sensitive of thyroid function

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(3) Metabolic Indexes

Although measurement of the metabolic impact of thyroid hormones have value in the investigative setting, none is sufficiently sensitive, specific, and easily performed for routine use Measurements of oxygen consumption in the BMR were once a mainstay in the diagnosis of thyroid disease, but not today

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(4) Tests of Homeostatic Control

Basal

serum TSH concentration Thyrotropin-releasing hormone Thyroid suppression test

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(5) Miscellaneous Tests

These do not assess thyroid function but are if value in defining the nature of the thyroid disorder or in planning therapy Example: some patients with autoimmune thyroid disease develop circulating antibodies against T3 and T4 resulting in sporadic highs and lows in the concentration of the hormones

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Hyperthyroidism

Clinical symptoms include: nervousness, palpitations, intolerance to heat, weight loss, muscle weakness, and fatigue Physical exam: smooth, moist skin,exopthalmus, presence of goiter, tachycardia, and hyperactive tendon reflex. Skin temperature is elevated, and there is fine tremor of the extended hands or a course tremor and jerking of trunk.

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Hyperthyroidism
Long-standing thyrotoxicosis Mild anemia and lymphocytosis are common Approximately 20% will have reduction in total WBC count

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Hyperthyroidism

Affects approximately 2% of women and 0.2% of men

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Causes of Hyperthyroidism
Graves disease (diffuse goiter and opthalmopathy) is the most common Graves disease typically occurs in women 20 to 40 years of age An autoimmune pathogenesis for Graves disease is suggested by presence of immunoglobulin G autoantiobodies

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Causes of Hyperthyroidism
Iatrogenicsecond most common cause. May result from administration of T3/T4 Toxic nodular goiter nodules functioning independently of normal feedback regulation Thyroiditis inflammation-induced release of thyroid hormones

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Treatment of Hyperthyroidism
Antithyroid Drugs Usual initial medical management Propylthiouracil,carbimazole, methimazole These drugs inhibit synthesis of inorganic iodide and coupling of iodothyronines Graves disease often initially treated with antithyroid drugs in hope of inducing a remission or achieving euthyroidism before surgery
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Treatment of Hyperthyroidism

Pregnant females should be treated with propylthiouracil (of antithyroid drugs it crosses placenta least), minimizing the risk of goiter any hypothyroidism in fetus Serious side effects of antithyroid drugs include agranulocytosis Intraoperative bleeding, from drug-induced thrombocytopenia or hypoprothrombinemia has been reported in patients on propylthiouracil Hypothyroidism is a risk of antithyroid drugs so patient may receive supplemental T4
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Treatment of Hyperthyroidism
Beta-Adrenergic Antagonists useful adjunctive therapies for patients with Graves disease diminish some of the S/S (tachycardia, anxiety, tremor) more rapidly than can antithyroid drugs Nadolol and atenolol have a longer duration than propranolol These drugs do not block the synthesis and secretion of thyroid hormones
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Treatment of Hyperthyroidism
Inorganic Iodine Iodine in pharmacologic doses (Lugols solution, 5% iodine, 10% potassium iodide in water) inhibits the release of T3 and T4 for a limited time (days to weeks) after which its antithyroid activity is lost Inorganic iodine is principally used to prepare pts. for surgery and treat thyrotoxic crisis
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Treatment of Hyperthyroidism

Radioiodine Therapy Often selected as tx of choice for hyperthyroidism that recurs following therapy with antithyroid drugs Objective is to destroy sufficient thyroid tissue to cure hyperthyroidism Permanent hypothyroidism is the only important complication of this therapy Pregnancy is an absolute contraindication as it may cause ablation of the fetal thyroid gland
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Treatment of Hyperthyroidism
Subtotal Thyroidectomy Used to treat Graves disease when radioiodine is refused, or for rare pts. With large goiters causing tracheal compression or cosmetic concerns If elective, pt. needs to be rendered euthyroid with drugs In emergency, pts. can be prepared for surgery in less than 1 hour by IV administration of esmolol
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Treatments to Render Hyperthyroid Pts. Euthyroid Prior to Surgery

Emergency Surgery Esmolol 100-300 mcg/kg/min IV until heart rate <100/min Elective Surgery Oral administration of Beta-adrenergic antagonist (propranolol, nadolol, atenolol) until heart rate <100/min Antithyroid drugs Antithyroid drugs plus potassium iodide Potassium iodide plus Beta-adrenergic antagonist
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Subtotal Thyroidectomy

Some uncommon complications include damage to recurrent laryngeal nerves, postop bleeding into the neck with resultant tracheal compression, and hypoparathyroidism Most common nerve injury is damage to abductor fibers of recurrent laryngeal This injury when unilateralhoarseness, and paralyzed vocal cord assuming an intermediate position
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Subtotal Thyroidectomy
Bilateral recurrent nerve injury results in aphonia and paralyzed vocal cords The cords can collapse together, producing total airway obstruction during inspiration Selective injury of adductor fibers of recurrent laryngeal nerves leaves the adductor fibers unopposed and pulmonary aspiration a hazard

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Subtotal Thyroidectomy
Airway obstruction that occurs soon after tracheal extubation, despite normal vocal cord function, suggests tracheomalacia This reflects a weakening of tracheal rings by chronic pressure of a goiter Airway obstruction postop (PACU) may be due to tracheal compression by a hematoma

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Subtotal Thyroidectomy

Hypoparathyroidism resulting from accidental removal of parathyroid gland rarely occurs after subtotal thyroidectomy If damage to parathyroids does occur, hypocalcemia typically develops 24 to 72 hours postop, but may manifest as early as 13 hours postop Laryngeal muscles sensitive to hypocalcemiamay go from inspiratory stridor progressing to laryngospasm. Prompt IV calcium till laryngeal stridor ceases is tx.
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Subtotal Thyroidectomy

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Thyroid Storm (Thyrotoxic Crisis)

Medical Emergency characterized by abrupt appearance of clinical signs of hyperthyroidism (tachycardia, hyperthermia, agitation, skeletal muscle weakness, CHF, dehydration, shock) due to the abrupt release of T4 and T3 into the circulation Can occur intraop but is more likely to occur 16-18 hours postoperative

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Thyroid Storm (Thyrotoxic Crisis)

When thyroid storm occurs intraop it may mimic malignant hyperthermia Treatment includes cooled crytalloids and continuous IV infusion of esmolol to maintain heart rate at acceptable level (usually < 100/min) When hypotension is persistent, the administration of cortisol, 100-200 mg IV may be a consideration

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Thyroid Storm (Thyrotoxic Crisis)

Propylthiouracil is given in dose of 100mg every 6 hours po or by NG tube to take advantage of the drugs ability to inhibit extrathyroidal conversion of T4 to T3 Potassium Iodide is also administered to block the release of T4 to T3 Also important to treat any suspected infection in these patients

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Management of Anesthesia
Elective

surgery should be deferred until the patient has been rendered euthyroid and the hyperdynamic cardiovascular system has been controlled with Beta adrenergic antagonists, as evidenced by an acceptable heart rate
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Management of Anesthesia
When

surgery cannot be delayed in symptomatic hyperthyroid patients, the continuous infusion of Esmolol, 100 to 300 mcg/kg/min IV may be useful for controlling cardiovascular responses evoked by the sympathetic nervous system
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Management of Anesthesia

Preoperative Medication: (a) benzodiazepines (b) use of anticholinergics not recommended as these drugs could interfere with the bodys own heatregulating mechanisms and contribute to an increased heart rate

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Management of Anesthesia
Preoperative: Evaluation of the upper airway for evidence of obstruction (goiter compressing on trachea) is extremely important Be prepared and have available in the O.R. needed equipment for a difficult airway and difficult intubation

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Management of Anesthesia
Induction: Propoful/Pentothal for induction Ketamine is not a likely selection as it can stimulate the sympathetic nervous system leading to a tachycardia Succinylcholine or non-depolarizers that do not affect the cardiovascular system for intubation (would avoid pancuronium)

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Maintenance of Anesthesia
(a)

(b)

Goals in maintenance of anesthesia in patients with hyperthyroidism are: Avoid administration of drugs that stimulate that stimulate the sympathetic nervous system Provide sufficient anesthetic-induced sympathetic nervous system depression to prevent exaggerated responses to surgical stimulation
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Maintenance of Anesthesia

Volatile anesthetics: (a) isoflurane, desflurane, sevoflurane, are good as they offset adverse sympathetic nervous system responses to surgical stimulation, but do not sensitize the heart to catecholamines (b) Remember sevoflurane and potential concern with nephrotoxicity caused by an increased production of fluoride owing to accelerated metabolism of this anesthetic
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Maintenance of Anesthesia
Monitor and keep track of patients body temperature (keep in mind thyroid storm) Vigilant monitoring of vital signs Pts. With exopthalmos prone to corneal ulcerations For antagonism of neuromuscular blockade with anticholinergics, it is best to avoid atropine and use glycopyrrolate as it has fewer chronotropic effects

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Maintenance of Anesthesia

(a)

Treatment of Hypotension:

When using sympathomimetic drugs must consider the possibility of exaggerated responsiveness of hyperthyroid pts. to endogenous or exogenous catecholamines (b) Therefore, decreased doses of direct-acting vasopressors such as phenylephrine may be a better choice than ephedrine, which acts in part by provoking the release of catecholamines
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Regional Anesthesia for Hyperthyroid Patients

Causes a sympathetic nervous system blockade May be a useful choice in hyperthyroid patients, assuming there is no evidence of high-output congestive heart failure Continuous epidural may be preferable to spinal because of the slower onset of sympathetic nervous system blockade

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Regional Anesthesia for Hyperthyroid Patients

If

hypotension occurs, decreased doses of phenylephrine are recommended Epinephrine should not be added to local anesthetics, as systemic absorption of this catecholamine could produce exaggerated circulatory responses
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Hypothyroidism
Decreased circulating concentration of T3 and T4 Present in 0.5% to 0.8% of adults Diagnosis based on clinical S/S plus confirmation of decreased thyroid gland function as demonstrated by appropriate tests

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Hypothyroidism
Causes: The etiology of hypothyroidism is categorized as (a) Primarydestruction of the thyroid gland (b) Secondarycentral nervous system dysfunction Chronic thyroiditis (Hashimotos thyroiditis) is the most common cause

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Etiology of Hypothyroidism
Primary Hypothyroidism Thyroid Gland Dysfunction Hashimotos thyroiditis Previous subtotal thyroidectomy Previous radioiodine therapy Irradiation of the neck

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Etiology of Hypothyroidism
Primary hypothyroidism Thyroid hormone deficiency Antithyroid drugs Excess iodide (inhibits release) Dietary iodine deficiency

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Etiology of Hypothyroidism
Secondary hypothyroidism Hypothalamic dysfunction Thyrotropin-releasing hormone deficiency Anterior pituitary dysfunction Thyrotropin hormone deficiency

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Hypothyroidism

Signs and Symptoms

-Decreased metabolic activity -Lethargy is prominent -Intolerance to cold -Cardiovascular changes are often the earliest clinical manifestations -bradycardia -decreased stroke volume and contractility -decreased cardiac output
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Hypothyroidism
-increased SVR -systemic hypertension, especially diastolic hypertension occurs in about 15% of hypothyroid patients -narrow pulse pressure -increased circulating concentrations of catecholamines -overt CHF is unlikely, but if present may indicate co-existing heart disease
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Hypothyroidism
Patients with hypothyroidism are predisposed to pericardial effusions The EKG may reveal low voltage, prolonged PR, QRS, and QT intervals due to pericardial effusion Conduction abnormalities may predispose patients to ventricular tachycardia, especially torsades de pointes

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Hypothyroidism
Thyroid hormone is necessary for normal production of pulmonary surfactant Chronic hypothyroidism is associated with pleural effusions Ventilatory drive to hypoxia and hypercapnia is decreased in patients with severe hypothyroidism BMR can be decreased up to 50% due to the hypothermia that occurs

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Hypothyroidism
Peripheral vasoconstriction characterized by cool, dry skin There is often atrophy of the adrenal cortex and associated decreases in the production of cortisol Inappropriate secretion of ADH can result in hyponatremia owing to the impaired ability of renal tubules to excrete free water

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Hypothyroidism
Treatment -Oral administration of T4 -Pts. With ischemic heart disease and hypothyroidism may not tolerate even modest amounts of T4 without developing angina -If angina appears or worsens during T4 therapy, coronary angiography and CABG may be necessary before adequate T4 therapy can be achieved
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Myxedema Coma
Rare complication of hypothyroidism Manifests as loss of deep tendon reflexes, spontaneous hypothermia, hypoventilation, cardiovascular collapse, coma, and death Sepsis in elderly or exposure to cold may be an initiating event

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Myxedema Coma
Treatment is with IV administration of T3, which exerts a physiologic effect within 6 hours Digitalis, as used to treat CHF, is used sparingly because the hypothyroid patients heart cannot easily perform increased myocardial contractile work Fluid therapy is important, but remember these patients may be vulnerable to water intoxication and hyponatremia

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Hypothyroidism
Management of Anesthesia -Elective surgery should be deferred if symptomatic -T4 drug has long half-life (7 days) and administration of it on day of surgery is optional -T3 drug has shorter half-life (1.5 days) so it may be prudent to have pt. take it on day of surgery

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Hypothyroidism
-Opioid premedication may be exaggerated in the hypothyroid patient -Supplemental cortisol may be considered if there is concern that surgical stress could unmask decreased adrenal function that may accompany hypothyroidism

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Maintenance of Anesthesia
Induction with pentothal, ketamine, or propoful Tracheal intubation with succinylcholine, or NDMR, but keep in mind that coexisting skeletal muscle weakness could be associated with an exaggerated drug effect

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Maintenance of Anesthesia
Often achieved with nitrous oxide + short-acting opioids, benzodiazepines, or ketamine Volatile anesthetics may not be recommended in overtly symptomatic hypothyroid pts. for fear of inducing exaggerated cardiac depression

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Maintenance of Anesthesia

Vasodilation produced by anesthetic drugs in the presence of hypovolemia could result in abrupt decrease in systemic blood pressure Pancuronium, because of its mild cardiovascular stimulating effects, may be selected for skeletal muscle paralysis Intermediate and short-acting NDMRs are good as they are less likely to produce a prolonged neuromuscular blockade
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Maintenance of Anesthesia
Monitoring hypothyroid pts. during anesthesia is intended to facilitate prompt recognition of exaggerated cardiovascular depression, and detection of onset of hypothermia Consider arterial line for long surgical procedures, or those associated with significant blood loss

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Maintenance of Anesthesia
IV fluids used should contain sodium to decrease likelihood of hyponatremia To treat hypotension it is best to use small increments of ephedrine 2.5 to 5.0 mg IV Phenylephrine could adversely increase SVR in the presence of a heart that cannot reliably increase its contractility

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Maintenance of Anesthesia
Suspect acute adrenal insufficiency when hypotension persists despite treatment with fluids and/or sympathomimetic drugs Maintain patients body temperature with use of a warming blanket or convection system, and warming of IV fluids

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Perioperative Period Possibilities

Increased sensitivity to depressant drugs Hypodynamic cardiovascular system responsesdecreased heart rate, decreased cardiac output Slow metabolism of drugs Hypovolemia Delayed gastric emptying Hyponatremia

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Perioperative Period Possibilities

Impaired ventilatory responses to arterial hypoxemia or hypercarbia Hypothermia Hypoglycemia Adrenal insufficiency

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Postoperative Management
Recovery from sedative effects of anesthetic drugs may be delayed Tracheal extubation should be delayed until the hypothyroid patient responds appropriately and their body temperature is near 37 degrees C Due to increased sensitivity to opioids, may want to consider nonopioid analgesic

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Extreme Goiter

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Goiter

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Shift of Trachea from Enlarged Right Lobe of Thyroid Gland

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