Case Report

Critical care unit team

Abu Keer insurance hospital

2011

History

A 21 years old female admitted for elective excision of a huge euthyroid goiter. Subtotal thyroidectomy was done, a sample was send for histo-pathological study.

Half an hour at the recovery room the patient developed stridor, which didn’t relieve with the usual conservative measures.

Patient was de-saturated (SpO2 < 80% on room air), so re-intubation at OR was done and the patient transferred to the ICU with T-piece after being seen by the head of the ICU department.

The patient seen by ENT surgeon post-operatively, vocal cord

was in cadaveric position.

History (cont..)

Even after re-intubation patient was still dyspnic, with SpO2 < 95% on high flow O2.

CXR was done after receiving the patient from the OR and stabilizing her vital signs revealed bilateral penumothorax.

At 7:00 PM patient vital signs became stable, with SpO2 =100%. Patient has been extubated under supervision of our consultant, who stay with patient for one hour after extubation and advice to continue conservative treatment and to do serial ABGs & CXR.

First CXR done post-operative in the ICU

History (cont..)

ROD called the head of ICU department because of deterioration of the general condition of the patient, after about 3 hours from extubation, which mandated re- intubation and connected to

mechanical ventilation by ROD. Data was:Data was: Mode: CPAP

PEEP: 5

PASB: 15

History (cont..)

ABG before & after MV. Data was:Data was:

Before MV:

pH=7,18 PO2=82,5 PCO2=56,5HCO3=17,8 BE=-6,8 SpO2=92,5%

After MV:

pH=7,28 PO2=76,9 PCO2=36,8HCO3=17,5 BE=-8,5 SpO2=94,5%

History (cont..)

The head of ICU department came to evaluate the patient at midnight and bilateral pneumothorax was the provisional diagnosis from the CXR done by the ROD before connection to the MV.

Cardiothoracic surgeon came at 2:00 AM and advice to continue conservative management (his opinion that the pneumothorax was mild at the time being).

History (cont..)

At the early morning follow up CXR revealed progression of bilateral pneumothorax with deterioration of the general condition, ABG withdrawn on T-piece showed sever hypoxia.

Data was:Data was:pH=7,41 PO2=47,3 PCO2=35,7 HCO3=23,3

BE=-1,4 SpO2=84,5%

Needle under water seal inserted bilaterally by cardiothoracic surgeon and ICU team, and patient was transferred to the OR urgently for bilateral IC tube insertion.

CXR done before needle aspiration

CXR done after needle aspiration

CXR after bilateral inter-costal tube insertion

CXR one day later shows good lung inflation with bilateral basal

pneumonic patches

History (cont..)

Extubation was done after the placement of the intercostal tubes. No stridor has been occurred, but the patient complained of dysphonia, aspiration on trial of oral feeding (juice) & episodes of early morning de-saturation (improved with suction, neublizer setting, & sometimes non-invasive MV) which improved gradually over the next 5 days.

History (cont..)

Left Intercostal tubes was removed at day 4 of ICU stay and the right at day 6.

Follow up CXR shows good lung inflation, with associated

bilateral basal lung consolidation atelectasis.

CXR few days later shows improvement in the pneumonic patches

)more evident on the left lung(

CXR 1 month later shows good lung inflation with no

residue

History (cont..)

At day 5, patient developed manifestation of hypocalemia, mainly as circum-oral tingling/numbness, muscle cramps followed by bilateral carpal spasm & sever agonizing body ache, relieved with calcium IV, and it showed a regression of it severity over the few next days on both oral (1.5 g Ca Carbonate), IV calcium gluconate & vitamin D supplement.

Typical carpal spasm

History (cont..)

Consultation team was advised by ICU consultant, pulmonology, general surgery, ENT (because of residual stridor & poor phonation), cardiothoracic consultants. All advice continue the same line treatment.

Patient was discharged after 11 days with good general condition, and on calcium supplement.

History (cont..)

Past history:Past history: None Except for pre-operative chest infection.

Drug history:Drug history:None.

Family history:Family history: Positive for familial goiter (her sisters & brother).

Occupational history:Occupational history:Works in cleaning printers with certain chemicals.

Laboratory finding Generally the initial laboratory finding was equivocal.

Few days later lab. Results shows: Hypocalcaemia (Total Calcium=7 mg/dl). Hypokalemia (Serum Potassium=3 mEq/L). Normal Phosphorous level (Serum phosphorous=3.5). Normal PTH level (PTH=13). Thyroid functions:

T3=,99 (N ,8-2) T4=7,2 (N 4,7-13,5) TSH=4,16 (N ,27-4,2)

Serial Calcium level showed improvement on the Serial Calcium level showed improvement on the calcium & vitamin D supplementcalcium & vitamin D supplement..

Culture & sensitivity

Sputum C/S:Sputum C/S: Gram positive cocci sensitive to vancomycine &

levofloxacine.

Blood C/S:Blood C/S: No growth.

Urine C/S:Urine C/S: No growth.

Histo-pathology Report

Hashimoto thyroiditis.

Lines of treatment

Anti-biotic therapy: Empirical: Vancomycine, & levofloxacine, which has

been continue after the C/S results. Corticosteroid therapy. Calcium supplement. Vitamin D-supplement. Magnesium infusion ( added after poor response to calcium

supplements alone). Potassium infusion. Eltroxine.

Problems encountered in the case are

StridorStridor

PneumothoraxPneumothorax

HypocalcaemiaHypocalcaemia

Sever chest infectionSever chest infection

PossiblePossible scenariosscenarios

Stridor

Anesthesia related: Laryngeal edema.

Surgery related: Hematoma. Bilateral recurrent laryngeal n. concussion. Hypocalcaemia due to hypo-parathyroidism.

Recurrent laryngeal nerve injury

It could be transient or permanent.

It could be unilateral (producing hoarseness of voice), or bilateral (producing stridor).

Trauma to the recurrent laryngeal nerve can be caused by ischaemia, traction, entrapment or transection of the nerve during surgery.

Recurrent laryngeal nerve injury (cont..) Nerve recovery is likely within a few days after surgery, but in

some cases, is known to take as long as twelve months.

Surgical measures may be necessary in patients with a persistently incompetent glottis, especially if compromising the airway.

Pneumothorax

Missed chest problem pre-operatively (regarding no CXR was done in the pre-operative setting).

Anesthesia related: Pulmonary Baro-trauma due to mechanical intermittent

pressure ventilation.

Surgery related: Injury to the Pleura during dissection.

Possible missed chest problem

Occupation related lung disease.Occupation related lung disease.

Goiter associated lung disorder:Goiter associated lung disorder: Auto-immune diseases associated with Hashimoto

thyroiditis like RA or SLE with lung involvement.

Gene association of familial MNG.

Familial MNG (diseases associated)

The DICER1 syndrome is characterized by rare benign and malignant tumors such as pleuropulmonary blastoma, multinodular goiter, nasal chondromesenchymal hamartoma, ovarian Sertoli-Leydig cell tumor, ocular medulloepithelioma, and

cystic nephroma.

Hypocalcemia

Hypo-parathyrodism.

Causes of Hypocalcaemia

Vitamin D deficiencyVitamin D deficiency Chronic renal failure.

Loss of Ca from circulationLoss of Ca from circulation

ExtraExtra--vascular depositionvascular deposition

•Hyperphosphataemia (renal failure, tumour

lysis).•Acute pancreatitis.

•Osteoblastic metastases (e.g. prostatic).

IntraIntra--vascular bindingvascular binding

•Citrate or blood products

•Foscarnet (anti-CMV drug(

•Acute respiratory alkalosis.

Causes of Hypocalcaemia (cont..)

HypoparathyroidismHypoparathyroidism Post parathyroid, thyroid, or neck surgery Idiopathic Pseudo-hypoparathyroidism Infiltration HIV infection

Disorders of MgDisorders of Mg metabolismmetabolism Magnesium deficiency

OtherOther Sepsis, burns Fluoride intoxication Chemotherapy (e.g. Cisplatin(

Hypocalcaemia (Clinical Hypocalcaemia (Clinical picture)picture) Neuromuscular:

* Circumoral tingling/numbness* Muscle cramps and numbness of the extremities* Tetany (manifest or latent)* Seizures* Stridor

Cardiovascular:* Hypotension* Prolonged QT interval* Arrhythmias.

Psychiatric manifestation as hallucination, emotional instability.

Papilledema

Post-operative Post-operative hypo-parathyroidismhypo-parathyroidism

It could be transient (ischemia of parathyroid) or permanent (accidental removal during thyroidectomy).

Clinical manifestations of hypocalcaemia occur 1 to 5 days post-operatively.

It usually transient and response to calcium & vitamin D

supplement.

Calcium Replacement TherapyCalcium Replacement Therapy

Hypocalcaemia could be treated with either oral or intravenous Ca supplement.

Intravenous calcium is indicated only for patients with symptomatic hypocalcemia.

Daily maintance dose in adult is 2 – 4mg daily, in the form of either Calcium carbonate or Calcium gluconate.

HypomagnesaemiaHypomagnesaemia

Mg is the second most abundant intra-cellular cation (after Ca).

Necessary for normal neuromuscular function.

Mg depletion is the most under diagnosed electrolyte abnormality in current medical practice.

Drugs such as diuretics, amino-glycoside, & increase losses via e.g: diarrhea considered as the most common causes of hypomagnesaemia.

Serum Mg level is an insensitive marker of Mg depletion.

Hypomagnesaemia (cont..)Hypomagnesaemia (cont..)

There’s no clinical picture specific to hypomagnesaemia, but there are suggestive clinical manifestations such as:

* Associated electrolyte abnormalities> Hypokalemia refractory to K replacement therapy.

> Hypocalcaemia ( due to impaired PTH release ).

* Arrhythmia> Mg depletion can promote digitalis cardio-toxicity.

> Torsdes de pointes arrhythmia.

* Neurological manifestations> CNS hyper-excitablity e.g: seizures, tremors, hyper-reflexia.

Torsdes de pointes arrhythmia

Hypomagnesaemia (cont..)Hypomagnesaemia (cont..)

Replacement of Mg could be done with either oral or parentral preparation depending on the severity of the clinical picture.

Consider Mg replacement whenever refractory hypokalemia or hypocalcaemia is present.

Hashimoto's Thyroiditis

chronic autoimmune inflammation of the thyroid with lymphocytes infiltration.

Patient presented with painless thyroid enlargement which maybe associated with hypothyroidism.

High titers of thyroid peroxidase antibodies (anti-TPO) is usually seen in such cases.

Lifelong l-thyroxine replacement is typically required.

Hashimoto's Thyroiditis (cont…)

It is sometimes associated with other autoimmune disorders, including: Addison's disease (adrenal insufficiency). Type 1 diabetes mellitus. Hypoparathyroidism. Vitiligo. Pernicious anemia. Connective tissue diseases (eg, RA, SLE, Sjögren's

syndrome). Schmidt's syndrome (Addison's disease, diabetes, and

hypothyroidism secondary to Hashimoto's thyroiditis).

Recommendations

Pre-operative chest X-ray to all patients especially those undergoing neck surgery.

Exclude retrosternal extension before thyroidectomy by CT neck.