Zhiling Xiong, MD, PhD, BWH Department of Anesthesiology INTRODUCTION

Currently at the BWH, the number of thyroidectomy procedures (total or partial) performed by general surgeons is about 1,000 cases per year. The most common pathogenic diseases are thyroid nodules, carcinoma, and goiters. Since the vocal cords (VCs) are innervated by the recurrent laryngeal nerve (RLN - a branch of the vagus), it is extremely important for anesthesiologists to monitor RLN nerve activity and to help surgeons identify this nerve intraoperatively in order to preserve VC function postoperatively. Due to the intraop RLN monitoring for each and every case, the incidence of the RLN injury in this institution (BWH) has dropped dramatically, to 0.3 0.4% (personal communication with Atul Gawande, MD), compared with the nation-wide incidence of about 5% (range 2 - 8%) without RLN monitoring(1). Depending on the individual surgeon and the patients thyroid lesion, partial (hemi -) thyroidectomy takes about 1-2 hrs (typically a DS case), and the total thyroidectomy takes about 2-3 hrs (always a SD case). All procedures require general anesthesia (GA) with endotracheal tube (ETT) intubation, and a LMA is best used as a conduit for fiberoptic bronchoscope to visualize the VC movement (RLN monitoring).

PREOPERATIVE
Nervena Laryngeal Stimulation Electrode (LSE) stickers The RLN monitoring is carried out by using a Nervena nerve stimulation system(2), which includes an EMG nerve stimulator, an LSE sticker (small and medium size) with two color coded wires, a stimulating forceps, and two electrode adaptors one for the surgeon, and one for the anesthesiologist. The adaptor for anesthesiologist use has three (3) connecting holes for wire plugin: middle hole for a ground electrode wire (placed at patients body surface such as forehead or shoulder) and two side holes for LSE sticker wires (color coded with one in red and one in blue). The LES sticker is taped on the ETT to have the electrodes contact with both sides of the VCs (see below). Detailed information about Nervena electrodes can be found on http://www.nerveana.com. Room Set-Up

Usually the regular room set-up and standard ASA monitoring will suffice. For better VC monitoring, a regular ETT of 7.0 (for most male) or 6.5 (for most female) is appropriate. Place an appropriate sized Nervena nerve stimulation sticker on the ETT, just 1-cm above the cuff. Make sure the sticker does not overlap the ETT. Therefore, the medium sized sticker (LSE 500M) is best placed on the 7.07.5 cm tube, and the small sized sticker (LSE 500Ms) is placed on the 5.0-6.5 ETT.

Have a regular LMA (#3 or #4) ready as a conduit for fiberoptic bronchoscope insertion for the VC monitoring. Make sure a monitoring tower with video display in the room, which should be set up by OR nursing team. A fiberoptic scope (pediatric or adult) in the room, and nursing team will provide a camera adapter for the monitoring during the operation.

Non-conventional airway devices (e.g., C-MAC, difficult airway cart) are sometimes needed in anticipation of difficult airway for some patients (see below). Patient Preparation Most patients airways are not particularly difficult. However, due to the nature and location of the thyroid lesion (such as large goiters), some patients tracheas and airways could be compressed and distorted, which causes respiratory distress and potential difficult intubation. Thus, it is imperative that these patients be carefully evaluated preoperatively, focusing on the history (respiratory symptoms during upright and supine position), physical exam (airway), and neck imaging study (CT scan). However, it should be noted that CT images often overestimate the severity of the tracheal compression. A 7.0 ETT usually can be easily passed through a severely compressed trachea, since the pathophysiology in this type of case differs from that of the anterior mediastinal mass. Intraoperative blood loss is usually not significant (<200 ml); one peripheral IV ( 20G) typically suffice. No Foley catheter is placed during the case.

INTRAOPERATIVE
Induction

Like any other GA cases, either IV (e.g., propofol) or inhalational agent (e.g., sevoflurane) induction can be used. Depending on the airway exam, difficult airway cart and devices (e.g., CMAC) may be needed.

Usually succinylcholine is given prior to intubation. NO LONG-ACTING MUSCLE RELAXANT SHOULD BE GIVEN due to the RLN monitoring. After intubation and the ETT being secured, a LMA is inserted behind the ETT. The depth of the ETT is confirmed with fiberoptic bronchoscope. Make sure b/l VC is visualized, and a thin blue line on the LSE sticker is just above (outside) the VCs.

Reposition of patient

Patients head/neck - a shoulder roll is placed, and the patients head and neck is carefully adjusted to a maximal extended position in order for better surgical exposure. Great attention should be paid to prevent obstruction of head venous return. Neck overextension should be avoided if patient has severe cervical arthritis. The head of the OR table is then elevated by 20 - 30 degrees.

Patients arm - both arms are tucked at the bedside; thus attention should be paid to the arm pressure points. Also double check the IV and the BP cuff to make sure they function appropriately.

Maintenance Since no long-acting muscle relaxant is used intraoperatively, patients should be anesthetized relatively deep to avoid movement during the surgery. To achieve this, remifentanil infusion (0.1-0.2 mcg/kg/min) is used in addition to the volatile agent (e.g., 1 MAC sevoflurane). Hemodynamic stability is maintained by giving vasopressor (e.,g, phenylephrine or ephedrine) boluss, or phenylephrine infusion as needed. BIS monitor is best placed to maintain the appropriate depth of anesthesia.

During the surgery, surgeon will intermittently stimulate the RLN (or the nerve-like fiber/structure), and will ask anesthesiologist to check the VC movement by using a fiberoptic bronchoscope. Hemostasis - towards the end of the surgery, the surgeon typically requests Trendelenberg position and positive pressure (30-35 cmH2O) bag ventilation for bleeding check. Thyroidectomy is usually not an exceedingly painful procedure. Prior to the skin incision, the surgeon injects 3-5 ml local anesthetic (mixture of 1% lidocaine and 0.5% bupivacaine) at the surgical site. Typically 150-200 mcg fentanyl is adequate for the pain control. Some patients may need an additional small dose of long acting opioids (e.g., 0.4 mg hydromorphone). During the emergence, all patients will receive 30 mg ketorolac (15 mg if renal insufficiency) unless contraindicated otherwise (e.g., allergic to NSAIDs or heavy intraop hemorrage) (see below). Emergence The goal of emergence is to have a smooth wake-up and to avoid HTN and coughing/bucking. Make sure ketorolac has been given at this stage. Ondansetron (4 mg) is best given to prevent N/V. Shoulder roll should be removed and the neck should be repositioned to a slight flexion with a gel donut to prevent the tension on the incision site. The head of table should be elevated by 30 - 45 degrees. As soon as patient regains consciousness, patient is extubated. Excessive HTN should be treated with more opioids (if pain) or an antihypertensive agent (e.g., esmolol or labetalol).

POSTOPERATIVE
After extubation and in PACU, patients head should be kept elevating by raising the HOB for 45 degrees. Avoid neck overextension. Again its very important to avoid HTN and pain to prevent hematoma, so give antihypertensive meds (e.g., labetalol, esmolol) and additional opioids if needed.

REFERENCES

Horne SK et al. Olaryngology-Head and Neck Surgery (2007) 136, 952-956. http://www.nerveana.com