Hyperthyroidism

[bentrider]

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I did a preop eval on a 55 year old patient for ORIF Hip. Labs showed undiagnosed hyperthyroidism (Free T4 over 5, TSH less than .03). Recent history of 50 lb weight loss. When should surgery and anesthesia proceed?

 

[periopdoc]

If asymptomatic (other than weight loss) initiate beta blockade and proceed. I would administer empiric stress dose steroids and be prepared for hyperthyroid crisis intraop.

If symptomatic (palpitations etc), then I would hold off for 12-24 hours of beta blockade +/- iodide treatment.

Obviously an elective case would get postponed until definitive control was obtained.

- pod

 

[bentrider]

Would you transfer case from community hospital without endocrinologist to academic medical center?

 

[periopdoc]

Depends. When you say transfer, do you mean across town 5 minutes away or do you mean a situation like mine where the closest academic center is 500 miles away. (Not that we would transfer this patient out)

The surgery is urgent in nature should not be delayed for transport. I would contact your local hospitalist/ internist and see how they would manage this patient if they did not require surgery and make your call based on that. If you do not have anyone who is comfortable managing this type of patient (assuming no fracture), then you have your answer and the patient should be transferred prior to surgery IMHO. If you have someone who is comfortable with run of the mill initial management of hyperthyroidism, then you probably are ok to proceed.

If you are looking at a short transport, but your orthopod feels that the surgery should be done prior to transport, I don't have a problem with it from an anesthetic standpoint.

I think the most important thing is to determine the disposition ahead of time and discuss that with your ortho colleague to best determine where the surgery should be done.

- pod

 

[jwk]

Would you transfer case from community hospital without endocrinologist to academic medical center?

Garden-variety average internists deal with hyperthyroid patients every day.

 

[Oggg]

Would you proceed if your hospital doesn't have an ICU?

 

[bentrider]

We transferred this patient since we did not have an endocrinologist on staff to help treat possible perioperative thyroid storm.

 

[Idiopathic]

We transferred this patient since we did not have an endocrinologist on staff to help treat possible perioperative thyroid storm.

anesthesiologist could treat this, but i dont see a problem with escalating the level of care here. intraop thyroid storm is rare but certainly happens and the prognosis is poor.

 

[Planktonmd]

I am wondering though: Why was the thyroid panel ordered before an ORIF of a hip???
If it wasn't ordered you most likely would have done the case and nothing happened.

 

[bentrider]

Patient had an elevated T4 in the recent past.