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
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
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
![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](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)