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Thyroid Gland and Anesthetic
Management
Daniel Stairs CRNA, MSN, MBA
Excela Health School of Anesthesia
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Thyroid Gland is H-shaped
Right and left lobe with isthmus
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Location of Thyroid Gland
Anterior to trachea
Just below cricoid cartilage
Covering second through fourth trachealrings
Thyroid gland weighs about 20 gm
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Blood Supply to Thyroid Gland
4 to 6 cc/min/gm
Arterial supplyvia inferior and superior
arteries
Venous supplyvia inferior, middle, and
superior thyroid veins
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Nerve Supply
Two superior laryngeal nervesand two recurrent laryngeal
nervessupply the entiresensory and motor innervations
to the larynx.
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Innervation
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Recurrent Laryngeal Nerve
Most common nerve injured inthroidectomy
Motor supply
Sensation below vocal cords
With selective injury to abductor fibers:
(1) hoarseness
(2) bilateral injury
(3) obstruction
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Recurrent Laryngeal Nerve
Selective injury to adduction fibers
Post-operative assessment after
thyroidectomy is via laryngoscopy and
having patient phonate letter e
Most common nerve injury
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Superior Laryngeal Nerve
Motor supply to cricothyroid muscle (SLN
external branch)
Internal branch provides sensation
above the vocal cords
Injury causes possible risk for aspiration
and hoarseness
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Essential Thyroid Hormones
Thyroxine orT4
Triiodothyronine orT3
Release of these hormones into circulation
stimulated by TSH
T3 is less firmly bound to carrier proteins and
disappears from circulation quicker
T3 is 3-5 times as potent as T4 but is limited byits transient nature
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Thyroid Hormones
Nearly all circulating T3 is derived fromperipheral conversion of T4
Major Functions of Thyroid
Hormones:(1) calorigenic effects
(2) growth and cellular differentiation
(3) metabolic effects(4) muscular effects
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Other Functions of Thyroid
Hormones
Working with growth hormone, they
ensure proper development of the brain
Increase protein breakdown and glucose
uptake by cells, enhance glycogenolysis.
and depress cholesterol levels
In excess they may interfere with ATP
synthesis and thus speed the exhaustion
of energy in muscle tissues
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Thyroid Hormones
Thyroxine
normal serum range is 5-12 mcg/dL
Triiodothyroninenormal serum range is 70-90 ng/dL
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Laboratory Testing of Thyroid
Hormone
Five General Categories
(1) Direct tests of thyroid function
(2) Tests relating to the concentration andbinding of thyroid hormones in blood
(3) Metabolic indexes
(4) Tests of homeostatic control of thyroid
function(5) Miscellaneous tests
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(1) Direct Tests
In-vivo administration of radioactive iodine
Thyroid Radioactive Iodine Uptake (RAIU) isthe most common
RAIU is measured 24 hours afteradministration of isotope
Normal is 10-30% of administered dose after
24 hours Values above normal indicate thyroid
hyperfunction
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(2) Tests Related to Hormone
Concentration and Binding
Are radioimmunoassays
Highly specific and sensitive
radioimmunoassays to measure serum
T3 and T4
Highly sensitive TSH assay is the most
sensitive of thyroid function
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(3) Metabolic Indexes
Although measurement of the metabolicimpact of thyroid hormones have value inthe investigative setting, none is
sufficiently sensitive, specific, and easilyperformed for routine use
Measurements of oxygen consumption inthe BMR were once a mainstay in thediagnosis of thyroid disease, but nottoday
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(4) Tests of Homeostatic Control
Basal serum TSH concentration
Thyrotropin-releasing hormone
Thyroid suppression test
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(5) Miscellaneous Tests
These do not assess thyroid function but
are if value in defining the nature of the
thyroid disorder or in planning therapy
Example: some patients with
autoimmune thyroid disease develop
circulating antibodies against T3 and T4
resulting in sporadic highs and lows inthe concentration of the hormones
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Hyperthyroidism
Clinical symptomsinclude: nervousness,
palpitations, intolerance to heat, weight loss,
muscle weakness, and fatigue
Physical exam: smooth, moistskin,exopthalmus, presence of goiter,
tachycardia, and hyperactive tendon reflex.
Skin temperature is elevated, and there is fine
tremor of the extended hands or a coursetremor and jerking of trunk.
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Hyperthyroidism
Long-standing thyrotoxicosis
Mild anemia and lymphocytosis are
common
Approximately 20% will have reduction in
total WBC count
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Hyperthyroidism
Affects approximately 2% of women and
0.2% of men
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Causes of Hyperthyroidism
Graves disease (diffuse goiter and
opthalmopathy) is the most common
Graves disease typically occurs in
women 20 to 40 years of age
An autoimmune pathogenesis for
Graves disease is suggested by
presence of immunoglobulin G
autoantiobodies
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Causes of Hyperthyroidism
Iatrogenicsecond most common
cause. May result from administration of
T3/T4
Toxic nodular goiternodules
functioning independently of normal
feedback regulation
Thyroiditisinflammation-induced
release of thyroid hormones
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Treatment of Hyperthyroidism
Antithyroid Drugs Usual initial medical management
Propylthiouracil,carbimazole, methimazole
These drugs inhibit synthesis of inorganic
iodide and coupling of iodothyronines
Graves disease often initially treated with
antithyroid drugs in hope of inducing aremission or achieving euthyroidism before
surgery
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Treatment of Hyperthyroidism
Pregnant females should be treated withpropylthiouracil(of antithyroid drugs it crossesplacenta least), minimizing the risk of goiterany hypothyroidism in fetus
Serious side effects of antithyroid drugsinclude agranulocytosis
Intraoperative bleeding, from drug-inducedthrombocytopenia or hypoprothrombinemia
has been reported in patients onpropylthiouracil
Hypothyroidism is a risk of antithyroid drugs sopatient may receive supplemental T4
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Treatment of Hyperthyroidism
Beta-Adrenergic Antagonists
useful adjunctive therapies for patientswith Graves disease diminish some of
the S/S (tachycardia, anxiety, tremor)more rapidly than can antithyroid drugs
Nadololand atenololhave a longer
duration than propranolol These drugs do not block the synthesis
and secretion of thyroid hormones
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Treatment of Hyperthyroidism
Inorganic Iodine
Iodine in pharmacologic doses (Lugolssolution, 5% iodine, 10% potassium
iodide in water) inhibits the release of T3and T4 for a limited time (days to weeks)after which its antithyroid activity is lost
Inorganic iodine is principally used toprepare pts. for surgery and treatthyrotoxic crisis
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Treatment of Hyperthyroidism
Radioiodine Therapy
Often selected as tx of choice forhyperthyroidism that recurs following therapywith antithyroid drugs
Objective is to destroy sufficient thyroid tissueto cure hyperthyroidism
Permanent hypothyroidism is the only
important complication of this therapy Pregnancy is an absolute contraindication as it
may cause ablation of the fetal thyroid gland
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Treatment of Hyperthyroidism
Subtotal Thyroidectomy
Used to treat Graves disease whenradioiodine is refused, or for rare pts. Withlarge goiters causing tracheal compression orcosmetic concerns
If elective, pt. needs to be rendered euthyroidwith drugs
In emergency, pts. can be prepared forsurgery in less than 1 hour by IVadministration of esmolol
T t t t R d H th id
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Treatments to Render Hyperthyroid
Pts. Euthyroid Prior to Surgery
Emergency SurgeryEsmolol 100-300 mcg/kg/min IV until heart rate
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Subtotal Thyroidectomy
Some uncommon complications include
damage to recurrent laryngeal nerves, postop
bleeding into the neck with resultant tracheal
compression, and hypoparathyroidism Most common nerve injury is damage to
abductor fibers of recurrent laryngeal
This injury when unilateralhoarseness, and
paralyzed vocal cord assuming an
intermediate position
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Subtotal Thyroidectomy
Bilateral recurrent nerve injury results inaphonia and paralyzed vocal cords
The cords can collapse together,
producing total airway obstruction duringinspiration
Selective injury of adductor fibers of
recurrent laryngeal nerves leaves theadductor fibers unopposed andpulmonary aspiration a hazard
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Subtotal Thyroidectomy
Airway obstruction that occurs soon after
tracheal extubation, despite normal vocal
cord function, suggests tracheomalacia
This reflects a weakening of tracheal
rings by chronic pressure of a goiter
Airway obstruction postop (PACU) may
be due to tracheal compression by ahematoma
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Subtotal Thyroidectomy
Hypoparathyroidism resulting from accidentalremoval of parathyroid gland rarely occursafter subtotal thyroidectomy
If damage to parathyroids does occur,hypocalcemia typically develops 24 to 72hours postop, but may manifest as early as 1-3 hours postop
Laryngeal muscles sensitive tohypocalcemiamay go from inspiratory stridorprogressing to laryngospasm. Prompt IVcalcium till laryngeal stridor ceases is tx.
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Subtotal Thyroidectomy
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Thyroid Storm (Thyrotoxic Crisis)
Medical Emergencycharacterized by
abrupt appearance of clinical signs of
hyperthyroidism (tachycardia,
hyperthermia, agitation, skeletal muscleweakness, CHF, dehydration, shock)
due to the abrupt release of T4 and T3
into the circulation Can occur intraop but is more likely to
occur 16-18 hours postoperative
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Thyroid Storm (Thyrotoxic Crisis)
When thyroid storm occurs intraop it maymimic malignant hyperthermia
Treatment includes cooled crytalloids
and continuous IV infusion of esmolol tomaintain heart rate at acceptable level(usually < 100/min)
When hypotension is persistent, theadministration of cortisol, 100-200 mg IVmay be a consideration
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Thyroid Storm (Thyrotoxic Crisis)
Propylthiouracilis given in dose of100mg every 6 hours po or by NG tubeto take advantage of the drugs ability to
inhibit extrathyroidal conversion of T4 toT3
Potassium Iodide is also administered toblock the release of T4 to T3
Also important to treat any suspectedinfection in these patients
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Management of Anesthesia
Elective surgery should be deferred
until the patient has been rendered
euthyroid and the hyperdynamic
cardiovascular system has been
controlled with Beta adrenergic
antagonists, as evidenced by anacceptable heart rate
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Management of Anesthesia
When surgery cannot be delayed in
symptomatic hyperthyroid patients,
the continuous infusion ofEsmolol,
100 to 300 mcg/kg/min IVmay be
useful for controlling cardiovascular
responses evoked by thesympathetic nervous system
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Management of Anesthesia
Preoperative Medication:
(a) benzodiazepines
(b) use of anticholinergics notrecommended as these drugs could
interfere with the bodys own heat-
regulating mechanisms and contribute to
an increased heart rate
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Management of Anesthesia
Preoperative:
Evaluation of the upper airway forevidence of obstruction (goiter
compressing on trachea) is extremelyimportant
Be prepared and have available in the
O.R. needed equipment for a difficultairway and difficult intubation
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Management of Anesthesia
Induction:
Propoful/Pentothal for induction
Ketamine is nota likely selection as it canstimulate the sympathetic nervous
system leading to a tachycardia
Succinylcholine or non-depolarizers that
do not affect the cardiovascular system
for intubation (would avoid pancuronium)
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Maintenance of Anesthesia
Goals in maintenance of anesthesiain patients with hyperthyroidism are:
(a) Avoid administration of drugs that
stimulate that stimulate the sympatheticnervous system
(b) Provide sufficient anesthetic-induced
sympathetic nervous systemdepression to prevent exaggeratedresponses to surgical stimulation
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Maintenance of Anesthesia
Volatile anesthetics:
(a) isoflurane, desflurane, sevoflurane, are good
as they offset adverse sympathetic nervous
system responses to surgical stimulation, butdo notsensitize the heart to catecholamines
(b) Remember sevoflurane and potential
concern with nephrotoxicity caused by an
increased production of fluoride owing toaccelerated metabolism of this anesthetic
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Maintenance of Anesthesia
Monitor and keep track of patients bodytemperature (keep in mind thyroid storm)
Vigilant monitoring of vital signs
Pts. With exopthalmos prone to cornealulcerations
For antagonism of neuromuscular
blockade with anticholinergics, it is bestto avoid atropine and use glycopyrrolateas it has fewer chronotropic effects
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Maintenance of Anesthesia
Treatment of Hypotension:
(a) When using sympathomimetic drugs must
consider the possibility of exaggerated
responsiveness of hyperthyroid pts. toendogenous or exogenous catecholamines
(b) Therefore, decreased doses of direct-acting
vasopressors such asphenylephrine may be
a better choice than ephedrine, which acts in
part by provoking the release of
catecholamines
Regional Anesthesia for
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Regional Anesthesia for
Hyperthyroid Patients
Causes a sympathetic nervous system
blockade
May be a useful choice in hyperthyroid
patients, assuming there is no evidence
of high-output congestive heart failure
Continuous epidural may be preferable
to spinal because of the slower onset ofsympathetic nervous system blockade
Regional Anesthesia for
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Regional Anesthesia for
Hyperthyroid Patients
If hypotension occurs, decreased
doses ofphenylephrine are
recommended
Epinephrine should not be added
to local anesthetics, as systemic
absorption of this catecholaminecould produce exaggerated
circulatory responses
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Hypothyroidism
Decreased circulating concentrationof T3 and T4
Present in 0.5% to 0.8% of adults
Diagnosis based on clinical S/S plus
confirmation of decreased thyroid gland
function as demonstrated by appropriate
tests
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Hypothyroidism
Causes: The etiology of
hypothyroidism is categorized as
(a) Primarydestruction of the thyroid
gland
(b) Secondarycentral nervous system
dysfunction
Chronic thyroiditis (Hashimotos thyroiditis)
is the most common cause
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Etiology of Hypothyroidism
Primary HypothyroidismThyroid Gland Dysfunction
Hashimotos thyroiditisPrevious subtotal thyroidectomy
Previous radioiodine therapy
Irradiation of the neck
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Etiology of Hypothyroidism
Primary hypothyroidism
Thyroid hormone deficiency
Antithyroid drugsExcess iodide (inhibits release)
Dietary iodine deficiency
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Etiology of Hypothyroidism
Secondary hypothyroidism
Hypothalamic dysfunction
Thyrotropin-releasing hormonedeficiency
Anterior pituitary dysfunction
Thyrotropin hormone deficiency
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Hypothyroidism
Signs and Symptoms-Decreased metabolic activity
-Lethargy is prominent
-Intolerance to cold-Cardiovascular changes are often the earliest
clinical manifestations
-bradycardia
-decreased stroke volume and contractility
-decreased cardiac output
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Hypothyroidism
-increased SVR
-systemic hypertension, especially diastolic
hypertension occurs in about 15% of
hypothyroid patients-narrow pulse pressure
-increased circulating concentrations of
catecholamines
-overt CHF is unlikely, but if present may
indicate co-existing heart disease
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Hypothyroidism
Patients with hypothyroidism arepredisposed to pericardial effusions
The EKG may reveal low voltage,
prolonged PR, QRS, and QT intervalsdue to pericardial effusion
Conduction abnormalities maypredispose patients to ventriculartachycardia, especially torsades depointes
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Hypothyroidism
Thyroid hormone is necessary for normalproduction of pulmonary surfactant
Chronic hypothyroidism is associated
with pleural effusions Ventilatory drive to hypoxia and
hypercapnia is decreased in patientswith severe hypothyroidism
BMR can be decreased up to 50% dueto the hypothermia that occurs
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Hypothyroidism
Peripheral vasoconstrictioncharacterized by cool, dry skin
There is often atrophy of the adrenal
cortex and associated decreases in theproduction of cortisol
Inappropriate secretion of ADH canresult in hyponatremia owing to theimpaired ability of renal tubules toexcrete free water
H h idi
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Hypothyroidism
Treatment-Oral administration of T4
-Pts. With ischemic heart disease and
hypothyroidism may not tolerate even modestamounts of T4 without developing angina
-If angina appears or worsens during T4
therapy, coronary angiography and CABGmay be necessary before adequate T4 therapy
can be achieved
M d C
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Myxedema Coma
Rare complication of hypothyroidism
Manifests as loss of deep tendon
reflexes, spontaneous hypothermia,
hypoventilation, cardiovascular collapse,coma, and death
Sepsis in elderly or exposure to cold may
be an initiating event
M d C
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Myxedema Coma
Treatment is with IV administration of T3,which exerts a physiologic effect within 6hours
Digitalis, as used to treat CHF, is usedsparingly because the hypothyroidpatients heart cannot easily performincreased myocardial contractile work
Fluid therapy is important, but rememberthese patients may be vulnerable towater intoxication and hyponatremia
H th idi
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Hypothyroidism
Management of Anesthesia
-Elective surgery should be deferred ifsymptomatic
-T4 drug has long half-life (7 days) andadministration of it on day of surgery isoptional
-T3 drug has shorter half-life (1.5 days) soit may be prudent to have pt. take it onday of surgery
H th idi
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Hypothyroidism
-Opioid premedication may be
exaggerated in the hypothyroid patient
-Supplemental cortisol may be considered
if there is concern that surgical stresscould unmask decreased adrenal
function that may accompany
hypothyroidism
M i t f A th i
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Maintenance of Anesthesia
Induction with pentothal, ketamine, or
propoful
Tracheal intubation with succinylcholine,
or NDMR, but keep in mind that co-existing skeletal muscle weakness could
be associated with an exaggerated drug
effect
M i t f A th i
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Maintenance of Anesthesia
Often achieved with nitrous oxide +
short-acting opioids, benzodiazepines, or
ketamine
Volatile anesthetics may not berecommended in overtly symptomatic
hypothyroid pts. for fear of inducing
exaggerated cardiac depression
M i t f A th i
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Maintenance of Anesthesia
Vasodilation produced by anesthetic drugs in
the presence of hypovolemia could result in
abrupt decrease in systemic blood pressure
Pancuronium, because of its mildcardiovascular stimulating effects, may be
selected for skeletal muscle paralysis
Intermediate and short-acting NDMRs are
good as they are less likely to produce aprolonged neuromuscular blockade
M i t f A th i
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Maintenance of Anesthesia
Monitoring hypothyroid pts. during
anesthesia is intended to facilitate
prompt recognition of exaggerated
cardiovascular depression, and detectionof onset of hypothermia
Consider arterial line for long surgical
procedures, or those associated withsignificant blood loss
M i t f A th i
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Maintenance of Anesthesia
IV fluids used should contain sodium to
decrease likelihood of hyponatremia
To treat hypotension it is best to use
small increments of ephedrine 2.5 to 5.0mg IV
Phenylephrine could adversely increase
SVR in the presence of a heart thatcannot reliably increase its contractility
M i t f A th i
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Maintenance of Anesthesia
Suspect acute adrenal insufficiency
when hypotension persists despite
treatment with fluids and/or
sympathomimetic drugs Maintain patients body temperature with
use of a warming blanket or convection
system, and warming of IV fluids
P i ti P i d P ibiliti
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Perioperative Period Possibilities
Increased sensitivity to depressant drugs
Hypodynamic cardiovascular systemresponsesdecreased heart rate,
decreased cardiac output Slow metabolism of drugs
Hypovolemia
Delayed gastric emptying Hyponatremia
Perioperative Period Possibilities
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Perioperative Period Possibilities
Impaired ventilatory responses to arterial
hypoxemia or hypercarbia
Hypothermia
Hypoglycemia
Adrenal insufficiency
Postoperative Management
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Postoperative Management
Recovery from sedative effects ofanesthetic drugs may be delayed
Tracheal extubation should be delayed
until the hypothyroid patient respondsappropriately and their body temperatureis near 37 degrees C
Due to increased sensitivity to opioids,may want to consider nonopioidanalgesic
Extreme Goiter
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Extreme Goiter
Goiter
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Goiter
Shift of Trachea from Enlarged Right
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g g
Lobe of Thyroid Gland
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