Recent case: Thyroidectomy

[sigrhoillusion]

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Case for discussion.

31 yo male with history of Graves disease. Poorly managed thyroid medications. Had thyroid storm leading to acute decompensated heart failure requiring ICU admission. EF 10% requiring Impella placement during hospitalization. Thyroid storm treated and upon discharge repeat ECHO showed EF 35%. Now coming back for total thyroidectomy.

What is your plan?

 

[WholeLottaGame7]

Case for discussion.

31 yo male with history of Graves disease. Poorly managed thyroid medications. Had thyroid storm leading to acute decompensated heart failure requiring ICU admission. EF 10% requiring Impella placement during hospitalization. Thyroid storm treated and upon discharge repeat ECHO showed EF 35%. Now coming back for total thyroidectomy.

What is your plan?

Prop sux tube.

Next.

 

[T-burglar]

Is there a sub sternal goiter or something?

Sux scop tube

 

[Noyac]

Prop sux tube.

Next.

What????
You would give this guy sux???
That’s barbaric.

What about the myalgias?

 

[Hork Bajir]

I'll bite.

Ensure patient is optimized medically- at the very least should be on propranolol, +/- PTU or methimazole, ballpark normotensive, no concerning EKG changes or end organ damage (AKI, etc). Induce however you see fit. Arterial line before induction (cue the usual debate, but with the arms tucked during the case and the chance of repeat thyroid storm when the gland is manipulated, I wouldn't take any chances). Uppers and downers in line- I'd probably run dilute peripheral levophed, and have nitroglycerin or clevidipine ready to go. Close communication with surgeon re: manipulation of thyroid, try to get venous drainage ligated ASAP (not sure if there's any evidence to back this up, but seems logical). Depending on pre and intra- op VS and HR, could also consider running an esmolol infusion (versus intermittent boluses). There's also some weak evidence for magnesium to decrease the risk of thyroid storm related arrhythmias, little downside so I'd probably work in 2g.

All of this is probably making a mountain out of a molehill, but it's our job to plan for the worst. Best case scenario case goes smoothly, no need for any fuss. Worst case scenario you could always drop a TEE probe, add inotropes, do the cardiac thing. The real key is making sure that the patient is well beta-blocked prior to coming to the OR.

 

[deleted875186]

Give anesthesia ....

Might need to elaborate on the current state of his heart failure symptoms, as well as his thyroid symptoms. If both are well controlled he should be good to go.

 

[Mr.S]

women get myalgias more than men. So I too would you use sux on this guy. Sometimes these thyroids you dont know where it begins or ends.
I would do this case without paralysis (since most likely the surgeons is using a neural integrity monitoring tube) I would run remi throughout the entire case. with an art line (pre induction) prob 0.5 mac of forane, 25mcg of fentanyl just to say i gave him something . I would have nitroglycerine and Neosynephrine available as needed. and as needed boluses of beta blocker. I would wake him up on remi after he opened his eyes on command
Done.

 

[sigrhoillusion]

What if the thyroid storm and acute heart failure occurred 2 weeks ago?
What if his TSH was low and his T3/T4 were elevated?
What do you consider "Euthyroid"? is it clinical based on signs, symptoms and vitals? Or do you care about labs?

 

[anbuitachi]

What if the thyroid storm and acute heart failure occurred 2 weeks ago?
What if his TSH was low and his T3/T4 were elevated?
What do you consider "Euthyroid"? is it clinical based on signs, symptoms and vitals? Or do you care about labs?

depends on how high/low his labs are. yes i care about labs.
also what was his management to treat his thyroid during the admission and what was he discharged on. any followup at all since that admission?

but otherwise it sounds like A line. prop sux tube.

 

[sigrhoillusion]

Surgeon had planned for thyroidectomy prior to discharge at ~1 week post thyroid storm. At that time his TSH <0.1 and T3/T4 were elevated and was on methimazole and b-blockers. But clinically improving. Decision at that time to postpone the procedure until labs improved. Patient returned a few weeks later and labs on that day were still abnormal but trending downward. Case went well (with a-line), but everything prepared for the worse. We were having a question in our group for when the best time to have done this case was. Whether it should have been done while patient still in hospital or whether wait for optimization.

I'm bringing up this issue, trying to find out if anyone has groups/institutes that have any cutoffs for these things? Do you require labs normalize, or just improving with no clinical signs of hyperthyroidism? Is there any benefit to delaying this due to recent heart failure? Let's say it's a CHF patient with acute HF, do you delay elective procedures or just wait until their symptoms improve? IF you do delay, how long?

I just find that there's so much variation in what people do. And our group in general have been trying to come up with some guidelines to prevent confusion and improve patient/surgeon satisfaction.

 

[DrOwnage]

Agree with above. His issue is basically an EF of 35% assuming he has good follow up. Probably about 25% of the patients in cath lab I deal with have EFs of 35% or lower and we do general anesthesia for pacemaker placements/revisions (basically the same level of simulation) without a gnarly game plan besides having rescue drugs ready and being considerate of induction doses. This guy should fly fairly easily unless you push 300mg of prop and 150mg of fentanyl on induction. If you are throwing in a TEE in a person getting a thyroidectomy they probably shouldn't be having the surgery in the first place.

 

[coffeebythelake]

Case for discussion.

31 yo male with history of Graves disease. Poorly managed thyroid medications. Had thyroid storm leading to acute decompensated heart failure requiring ICU admission. EF 10% requiring Impella placement during hospitalization. Thyroid storm treated and upon discharge repeat ECHO showed EF 35%. Now coming back for total thyroidectomy.

What is your plan?

Is graves controlled now on Rx? PTU/methimazole/RAI? If not well suppressed... delay surgery until it is.

 

[Planktonmd]

What????
You would give this guy sux???
That’s barbaric.

What about the myalgias?

🤣

 

[Planktonmd]

I think the described plan of waiting a few weeks to allow the heart to recover and the thyroid function to improve is a reasonable plan. I would proceed with surgery while being prepared to treat an intra-op thyroid storm if it occurs.

 

[Noyac]

I agree with the “Plank”.
I would speak with cardiology to get a sense of how much the heart will recover and when since I am not an expert on this subject. If they expect 50%EF in 4weeks then I’d like to wait. If they say 35% is as good as it gets in the next few weeks then fine. I would not want to take him to the OR at 10% and then try to deal with a thyroid storm in this condition.