the anesthetic considerations for parathyroid resection?
It is important to know the indication for the
surgery. If the patient has secondary hyperparathyroidism from end-stage renal
disease, it is important to consider all the impli-cations of renal failure and
its comorbidities. These patients are likely to have hypertension, diabetes
mellitus, and coronary artery disease, as well as metabolic derange-ments from
For patients presenting with primary
hyperparathy-roidism, it is important to know the calcium concentration and
whether the patient is symptomatic. Hypercalcemia causing significant symptoms
should be corrected preop-eratively. Isolated parathyroid adenomas that have
been localized preoperatively can be excised under general anes-thesia,
regional anesthesia with unilateral deep and super-ficial cervical blocks, or
sedation and local anesthesia. The experience and comfort level of the surgeon
and patient expectations play a large role in the choice of anesthetic plan.
Surgery for all four glands or for poorly localized ade-nomas is more easily
performed under general anesthesia. It is difficult to obtain adequate regional
anesthesia bilat-erally. Bilateral deep cervical plexus blocks can cause
bilateral recurrent laryngeal nerve paralysis or bilateral phrenic nerve
paralysis, and are relatively contraindicated. More surgeons are becoming
comfortable with performing bilateral neck exploration under local anesthesia.
It is now commonplace to monitor PTH levels
before and after adenoma resection. After successful resection, PTH levels
should fall by half within 10 minutes. A large-bore intravenous catheter in an
antecubital vein usually provides adequate blood flow to obtain specimens.
Alternatively, it is sometimes necessary to place a catheter in a foot, or
perform repeat venipuncture in a foot to obtain specimens. Rarely, an arterial
line can be placed for the case, but the risk-benefit ratio must be carefully
con-sidered. The arms are usually tucked by the patient’s side and are
inaccessible during surgery.