Thyroid Disease and Anesthetic

Considerations
Jose Soliz, M.D.
LBJ Grand Rounds
February 2004

Basic Thyroid Gland Physiology
Hormones triiodothyronine (T3) and thyroxine
(T4) are bound to proteins and stored in the
thyroid gland.
T3 is more potent and less protein bound, most
T3 is made in peripheral tissues from the de-
iodination of T4
Both hormones increase carbohydrate and fat
metabolism, increasing metabolic rate, minute
ventilation, heart rate and contractility, water /
electrolyte balance, normal function of CNS.

Hyperthyroidism
Causes
Graves Disease-most common
toxic multinodular goiter
TSH hormone secreting pituitary tumors
functioning thyroid adenomas
overdose of thyroid replacement medication
Hyperthyroidism

Diagnosis: made by abnormal TFTs, elevated total and
free T4, T3 low TSH, elevated free thyroxine index
Medical Treatment consists of drugs that inhibit hormone
synthesis (PTU-propylthiouracil, MMI-methimazole),
inhibit hormone release (potassium, or sodium iodide) or
mask the signs of adrenergic activity (Beta-blocker)
While Beta blockade does not affect thyroid gland
function, it does decrease the peripheral conversion of T4
to T3.
Radioactive iodine and subtotal thyroidectomy are other
alternatives to medical therapy
Hyperthyroidism
Clinical Manifestations
Weight loss
heat intolerance
muscle weakness
diarrhea
hyperactive reflexes
nervousness / anxiety
Physical: fine tremor, exophthalmos, goiter, warm clammy
skin, fine brittle hair
Cardiac: sinus tach, A Fib, increase in contractility, CO
Hyperthyroidism
Anesthetic considerations-Preoperative
Antithyroid medications and beta-blockers should be
continued through the morning of surgery.
Miller: Ideally patient should be rendered euthyroid
prior to any elective procedure. Beginning pre-op
antithyroid meds take 2-6weeks for effect, can use
KI with Beta-blocker in addition, or alternative
Benzodiazepines are good choice for pre-operative
sedation
Careful evaluation of patients airway
Hyperthyroidism
Anesthetic considerations-Intraoperative
No controlled study suggest advantages of
particular anesthetic drug or technique for
hyperthyroid patients, however:
Drugs that stimulate sympathetic nervous system
should be avoided because of the possibility of
large increases in blood pressure and heart rate.
Ex. Ketamine. Pancuronium, atropine, ephedrine,
epi
Thiopental may be induction agent of choice as it
possess antithyroid activity at high doses.

Hyperthyroidism
Anesthetic considerations-Intraoperative
Close monitoring of cardiac function and body
temperature is required. Need for invasive
monitoring?
Adequate anesthetic depth should be obtained
prior to laryngoscopy or surgical stimulation to
avoid tachycardia, hypertension, ventricular
dysrhythmias
Eye protection

Hyperthyroidism
Anesthetic considerations-Intraoperative
Anticipate exaggerated hypotensive response
during induction as patient may be hypovolemic
Muscle relaxants can be given safely. Note
patients with autoimmune thyrotoxicosis are
associated with an increase risk of myopathies and
myasthenia gravis. Reversal with glycopyrrolate
instead of atropine
Hyperthyroidism does NOT increase MAC
requirements, volatile agents can be used safely

Hyperthyroidism
Anesthetic considerations-Postoperative
Thyroid storm is most serious post-op problem
Characterized by: hyperpyrexia, tachycardia, altered
consciousness, and hypertension
Precipitating factors: infection, trauma, surgery
Incidence is 10% in patients hospitalized for thyrotoxicosis
Onset is usually 6-24 hours after surgery, but can happen
intraoperatively mimicking malignant hyperthermia
Unlike MH, not associated with muscle rigidity, elevated
CPK, or marked degree or lactic or respiratory acidosis
Hyperthyroidism
Anesthetic considerations-Thyroid Storm
Treatment: ABCs
IV Hydration, cool patient
IV propanolol (.5mg increments)/esmolol to control heart
rate until less than 100.
Propylthiouracil 250mg Q6 hours orally or by NG tube
Sodium Iodide 1 gram over 12 hours
correction of any precipitating events (infection)
Cortisol is recommended if there is any coexisting adrenal
gland suppression
Mortality rate is approximately 20%
Anesthetic Considerations
Subtotal Thyroidectomy
Associated with several complications:
Recurrent laryngeal nerve palsy may cause hoarseness if
unilateral, or stridor if bilateral
Vocal cord function may be evaluated by DL after deep
extubation if there is concern
Hematoma formation may cause airway compromise. May
require immediate opening of neck wound
Hypoparathyroidism may result from unintentional
removal of parathyroid glands. Hypocalcemia will result
within 24-72 hours
Pneumothorax
Hypothyroidism
Causes
Primary hypothyroidism
Autoimmune (Hashimotos thyroiditis)
post thyroidectomy
post radioactive iodine
overdosage of antithyroid medication
iodine deficiency
secondary hypothyroidism (failure of the
hypothalamic-pituitary axis)
Hypothyroidism

Incidence: 1% of adult population, ten times more
prevalent in women

Diagnosis: can be confirmed by low free
thyroxine levels and elevated TSH (if primary)

Medical Treatment: consist of oral replacement
Hypothyroidism
Clinical Manifestations
Hypothyroidism in early neonatal development
may result in cretinism.
In adults, manifestations can be subtle: weight
gain, cold intolerance, muscle fatigue, lethargy,
constipation, hypoactive muscle reflexes,
depression, periorbital or pretibial swelling
Heart rate, contractility, stroke volume, and
cardiac output decrease, extremities may be cold,
hair may be coarse and brittle.

Hypothyroidism
Anesthetic considerations-Preoperative
Patients with uncorrected severe hypothyroidism (T4<1 ug/dL)
or myxedema coma should not undergo elective surgery.
Potential for severe cardiovascular instability intraoperatively
and myxedema coma.
If emergency surgery is necessary, in patients with overt
disease or myxedema coma, IV thyroxine and steroid coverage.
Euthyroid state is ideal, however, subclinical cases of
hypothyroidism has not been shown to significantly increase
risk of surgery
Continue thyroid replacement meds on morning of surgery


Hypothyroidism
Anesthetic considerations-Preoperative
Airway eval: patients tend to be obese, large tongue, short
neck, goiter, swelling of upper airway
Pre-op sedation should be administered cautiously if at all, as
patients are more prone to drug included respiratory depression
from sedatives and narcotics
Consider aspiration prophylaxis with Bicitra, Reglan as many
hypothyroid patients have delayed gastric emptying times



Hypothyroidism
Anesthetic considerations-Intraoperative
Patients are more sensitive to hypotensive effects of
anesthetic agents because decreased cardiac output,
blunted baroreceptor reflexes, and decreased intravascular
volume. Invasive monitoring on a per patient basis
Ketamine or Etomidate may be induction agents of choice
Succinylcholine and non-depolarizing muscle relaxants are
generally safe for use. Monitor with peripheral nerve stim.
Controlled ventilation is recommended as patients tend to
hypoventilate



Hypothyroidism
Anesthetic considerations-Intraoperative
Hypothermia occurs quickly and difficult to
prevent and treat
MAC is essentially unchanged
Hematological (anemia, platelet, coag dysfx),
electrolyte imbalances, and hypoglycemia is
common and require close monitoring
intraoperatively
Consider co-existed adrenal insufficiency in
causes of refractory hypotension
Hypothyroidism
Anesthetic considerations-Myxedema Coma
Rare form of decompensated Hypothyroidism
characterized by stupor or coma, hypoventilation,
hypothermia, bradycardia, hypotension, and
severe dilutional hyponatremia(SIADH), CHF
Medical emergency with mortality rate of 15-20%
Infection, trauma, cold, CNS depressants
predispose hypothyroid patients, especially in
elderly

Hypothyroidism
Anesthetic considerations-Myxedema Coma
Treatment
IV thyroxine is indicated (L-thyroxine loading
dose 300-500ug, followed by 50ug/day for 24-
48hrs)
IV hydration with dextrose containing crystalloid,
correction of electrolyte abnormalities
Support cardiovascular and pulmonary systems as
necessary

Hypothyroidism
Anesthetic considerations-Postoperative
Extubation/Emergence may be delayed secondary
to hypothermia, respiratory depression, or slowed
drug metabolism
Awake extubation, try to maintain normothermia
Cautiously administer opioids post-op, consider
regional techniques or Ketorolac for post-op pain
control

References:
1. Graham, GW, Unger, BP, Coursin DB. Perioperative Management
of Selected Endocrine Disorders. International Anesthesiology Clinics.
38(4) pp..31-67, 2000
2. Langley RW, Burch HB. Perioperative Management of the
Thyrotoxic Patient. Endocrinology and Metabolism Clinics of North
America. 32, 519-534, 2003
3. Miller, RD, Cucchiare RF, Miller ED, et al. Anesthesia, 5th ed.
Churchiill-Livingston. New York, pp.927-933, 2000.
4. Morgan GE, Mikhail MS. Clinical Anesthesiology, New York,
McGraw-Hill, 1996, 639-641
5. Murkin, JM. Anesthesia and Hypothyroidism: A Review of
thyroxine physiology, pharmacology, and anesthetic complications.
Anesthesia and Analgesia. Vol61(4) April 1982








References:(cont.)
6. Nicoloff JT, LoPresti JS: Myxedema Coma: A Form of
Decompensated Hypothyroidism. Endocrinology Clinics of North
America, Philadelphia, WB Saunders, June 1993 279-290
7.Stathalos N, Wartofsky L. Perioperative Management of Patients
with Hypothyroidism. Endocrinology Clinics of North America. 32,
pp..503-518, 2003
8. Wall R. Unusual Endocrine Problems. Anesthesiology Clinics of
North America 14, 471-493, 1996
9. Weinberg AD, Brennan MD, Gorman CA et al. Outcome of
Anesthesia and Surgery in Hypothyroid patients. Arch Intern Med
143:893-897, 1983