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Thyroid

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  • 1. Making the patient euthyroid Mathew John MD, DM, DNB Consultant Endocrinologist
  • 2. 1866 – “If a surgeon should be so foolhardy as to undertake it [thyroidectomy] … every step of the way will be environed with difficulty, every stroke of his knife will be followed by a torrent of blood, and lucky will it be for him if his victim lives long enough to enable him to finish his horrid Samuel Gross (standing) in The Gross Clinic butchery.” by Thomas Eakins Samuel David Gross http://en.wikipedia.org/wiki/Samuel_D._Gross
  • 3. 1920 “feat which today can be accomplished by any competent operator without danger of mishap” Halsted WS: The operative story of goiter. Johns Hopkins Hosp Rep 19:71, 1920
  • 4. Agenda • Making a thyrotoxic patient euthyroid before thyroid surgery • Making a hypothyroid patient euthyroid before surgery • Post operative management Thyrotoxic patient Euthyroid/hypothyroid Not in discussion • Preparing patients with hypothyroidism and hyperthyroidism for non thyroid surgeries • Hypocalcaemia management
  • 5. Thyroid diseases presenting for surgery • Euthyroid : Multinodular goiter Solitary thyroid nodule • Hyperthyroid : Toxic MNG : Autonomous functioning thyroid nodule : Graves’ s disease with large goiter/cold nodule • Thyroid malignancy • Emergency thyroidectomy : obstructed : allergic to anti thyroid meds : Amiadarone induced thyrotoxicosis : thyroid crisis
  • 6. Thyroid diseases presenting for surgery • Euthyroid : Multinodular goiter Solitary thyroid nodule • Hyperthyroid : Toxic MNG : Autonomous functioning thyroid nodule : Graves’ s disease with large goiter/cold nodule • Thyroid malignancy • Emergency thyroidectomy : obstructed : allergic to anti thyroid meds : Amiadarone induced thyrotoxicosis : thyroid crisis
  • 7. Functional status of thyroid Euthyroid Hypothyroid Hyperthyroid No preparation Thyroxine •Antithyroid drugs(ATD) supplementation •Iodine •Steroids
  • 8. Graves’ disease vs. AFTN vs. Toxic MNG Grave’s disease Autonomously Toxic MNG functioning thyroid nodule ( AFTN)
  • 9. Why should a toxic patient be euthyroid before surgery ? • Thyrotoxic crisis • Cardiac arrhythmias and tachycardia • Worsening of co existent medical conditions: Cardiovascular Diabetes mellitus Blood pressure • Hemodynamic compromise • Anesthetic drug interactions
  • 10. Euthyroidism • Clinically normal: no symptoms, heart rate, tremors, sweating, weight gain, normal appetite • Normal thyroid function tests ( in steady state ) • Thyroid adequately blocked so that hormones are not released during surgical manipulation
  • 11. Graves’s disease • Thyroid hormone production driven by TSH receptor stimulating antibodies • Choice of ablative therapy: radioactive iodine ablation • Indications for surgery 1. Large goiter: obstructive 2. Solitary cold nodule 3. Allergic to ATD 4. Pregnancy (requiring high dose ATD) TSH: thyroid stimulating hormone ATD: antithyroid drugs
  • 12. Treatment options Anti thyroid drugs Iodine Beta blockers •Carbimazole •Lugols iodine •Propranolol •PTU •SSKI •Esmolol •Iopanoic acid •Blocks synthesis •Blocks uptake of •Reduces toxic •Blocks release iodine symptoms •Reduces peripheral • Blocks oxidation •Reduces peripheral conversion •Blocks organification conversion •Blocks release • Reduces peripheral conversion
  • 13. Making the patient euthyroid • Anti thyroid drugs : Carbimazole vs. PTU • Start Carbimazole 10-30 mg/day based on severity of symptoms and time left for surgery • Start beta blockers: T. Propranolol 30-120 mg/day • Call back after 6 weeks and reassess
  • 14. Beta blockers • Reduces peripheral symptoms • Reduces myocardial oxygen consumption, reduces heart rate, improves myocardial efficiency • Used to prepare patients for surgery • Used with caution in patients with congestive heart failure, bronchial asthma • Useful in thyrotoxic crisis
  • 15. Do we need to use iodine ? • Given after making the patient euthyroid by ATD • Benefits: Involution of the gland Decreases its vascularity, (decreased rate of intraoperative blood loss) • Contraindicated in toxic multinodular goiter and AFTN AFTN : Autonomously functioning thyroid nodule ATD: antithyroid drugs Erbil Y,. Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves' disease. J Clin Endocrinol Metab. 2007 Jun;92(6):2182-9
  • 16. There was no difference irrespective of treating with iodine in blood loss or other ease of surgery or crisis
  • 17. Alternate methods of preparation • Block replacement therapy : Carbimazole ( PTU) + Thyroxine • Potassium iodide + beta-blocker • Iopanoic acid + Propranolol : used for rapid preparation in Amiadarone induced thyrotoxicosis Feek CM, Stewart J, Sawers A, Irvine WJ, Beckett GJ, Ratcliffe WA, Toft AD: Combination of potassium iodide and propranolol in preparation of patients with Graves' disease for thyroid surgery. N Engl J Med 302:883, 1980 Bogazzi F, Martino E. Preparation with Iopanoic acid rapidly controls thyrotoxicosis in patients with amiodarone-induced thyrotoxicosis before thyroidectomy. Surgery 132:1114-1117, 2002
  • 18. Toxic MNG/ AFTN • Less risk of thyroid crisis • Make patient euthyroid before surgery • Consider using beta –blocker and small dose anti thyroid drugs before surgery • Do not use iodine for preparation
  • 19. Post operative treatment • Stop antithyroid drugs after surgery • Beta blockers can be stopped after 2-3 days • Await the histopathology : if benign start Thyroxine
  • 20. Calcium metabolism • Monitor calcium after 12-24 hours or if hypocalcaemia symptoms present • Hypocalcaemia : hypoparathyroidism hungry bone syndrome • If S. Calcium (corrected) < 8.5 mg/dl : supplement calcium with (active) Vitamin D • Calcium supplements for all operated thyrotoxic patients
  • 21. Maria Maria Richsel Richsel Kocher T: Uber Kropfextirpation und ihre Folgen. Arch Klin Chir 29:254, 1883.
  • 22. Hypothyroidism after surgery • Varying estimates • Depending on the gland left behind • Total thyroidectomy : 100 % have hypothyroidism • Mechanism of hypothyroidism: reduced thyroid volume thyroid autoimmunity reduced vascularity
  • 23. Subclinical hyperthyroidism • Normal T4, T3 Suppressed TSH • Suggests mild overproduction of thyroid hormone • Less risk of thyroid crisis • Consider using beta –blocker and small dose anti thyroid drugs before surgery
  • 24. Hypothyroidism Overt hypothyroidism Subclinical • Low T4 hypothyroidism • Normal T4 • Elevated TSH • Mildly elevated TSH (usually < 10 mIU/ml ) • Does not carry any increased risk
  • 25. Hypothyroidism • May be seen in large goitrous Hashimoto’s thyroiditis • Overt hypothyroidism is unusual in thyroid surgical cases
  • 26. Risks of untreated hypothyroidism • Myxedema coma • Electrolyte imbalance • Hypoventilation • Delayed recovery from anesthesia • Hypothermia
  • 27. Achieve euthyroidism before surgery
  • 28. Achieving euthyroidism • Start Thyroxin 50 -100 mcg/day • Call back patient after 6 weeks • Check T4, TSH • If both are normal, the patient can be taken up for surgery with no additional risk
  • 29. Message • Hyperthyroidism and hypothyroidism are common in patients undergoing thyroid surgery • Making the patient euthyroid improves outcomes • Hyperthyroidism is treated with 1. Anti thyroid drugs 2. Beta blockers 3. Iodine • Hypothyroidism is managed with Thyroxine
  • 30. Thank you Patient information www.endocrinologydiabetes.com