What are
the preoperative considerations in a patient with thyroid disease?
The first, and most important, consideration is
whether the patient is clinically euthyroid. Patients who are euthy-roid or
minimally hypothyroid are generally at no increased perioperative risk.
However, patients who are clinically hyperthyroid may have dysrhythmias,
hyper-tension, ischemia, high-output cardiac failure, and ultimately may
develop thyroid storm. Conversely, patients who are clinically hypothyroid may
have bradycardia, hypotension, low-output cardiac failure, and resistance to
catecholamines.
Patients who are hyperthyroid must be treated
preoper-atively. For elective cases, this should include PTU or methimazole
until the patient is euthyroid, which may take 6–8 weeks of therapy. The
addition of β-blocking agents may also be necessary. For urgent or emergent
cases, the patient should be treated with β-blocking agents.
Profoundly hypothyroid patients should receive
intra-venous T4 before surgery. Patients should be observed
care-fully for dysrhythmias or angina.
Any patient with a goiter must be evaluated for
airway compromise. Large goiters can cause distortion of the air-way, making
intubation difficult or impossible. Goiters also make emergency surgical access
of the airway difficult if not impossible and therefore should not be
considered a viable emergency back-up plan. Retrosternal goiters can cause
collapse of the airway after induction of general anesthesia. Symptoms such as
dysphagia, wheezing, stri-dor, and positional dyspnea are worrisome and
necessitate further evaluation (see below). Physical examination should include
the standard evaluation of the airway, as well as position of the trachea. Any
plan for an awake fiberoptic intubation should be discussed with the patient
preoperatively.
Patients who are euthyroid or hyperthyroid can
safely receive preoperative anxiolysis. However, premedication in patients who
are hypothyroid should be avoided because they may have an exaggerated and life-threatening
response to anxiolysis.
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