Hyperthyroidism / Thyroid storm

 

 

 

Considerations

 

  • Potential difficult airway if goitre present (airway compression, anterior mediastinal mass)

  • End organ effects of chronic hyperthyroidism:

    • Hypermetabolic state (↑ VO2, VCO2)

    • Cardiovascular: hypertension, tachycardia, myocardial ischemia, cardiomyopathy, arrhythmias

    • CNS: anxiety, psychiatric disorders

    • Muscle weakness

  • Risk of thyroid storm

  • Interactions with anesthetics:

    • ↑ anesthetic requirements to control BP & HR.  MAC requirement is NOT increased

    • Avoid sympathetic stimulants (ketamine, cocaine, epinephrine, etc)

  • Thyroidectomy:

    • Shared airway

    • Airway obstruction (tracheomalacia, recurrent laryngeal nerve injury, neck hematoma, hypocalcemia)

 


Optimization

 

  • Optimize thyroid function & limit end organ effects: heart rate <90, normal TSH

  • Identify difficult airway or anterior mediastinal mass

  • Identify & manage thyroid storm

 

 

Conflicts

 

  • Difficult airway/hemodynamic instability & sympathetic stimulants (cocaine, epinephrine, glycopyrrolate)

  • Hemodynamic instability & RSI

 

 

Thyroid storm

 

  • Emergency situation (mortality= 20%), consider endocrinology consult 

  • IV fluids

  • Cool (blankets, IV solution, acetaminophen)

  • Control hemodynamics:

    • Esmolol 0.25-0.5 mg/kg bolus or 50-200 mcg/kg/min infusion

    • Propranolol 10-40 mg PO or up to 1 mg/min IV

  • Stop conversion of T4 to T3:

    • PTU 200-400 mg PO/NG/PR q6h

    • Hydrocortisone 100-200 mg IV q8h

  • Stop synthesis & release of new hormone:

    • Potassium iodide 5 gtts PO/NG q6h or sodium iodide 0.25 g IV q6h (1 hr after PTU)

  • Look for & treat complications:

    • CVA, loss of consciousness

    • Myocardial infarction, atrial fibrillation (avoid amiodarone because of iodide content; use digoxin instead) or congestive heart failure

    • Hypoventilation & hypercarbia

    • Electrolyte abnormalities

  • Consider differential diagnosis for hypermetabolic state

  • Consider last ditch treatments: plasmapheresis, dantrolene, lithium, neuraxial blockade to T4



 

 All rights reserved 2017 © anesthesiaconsiderations.com

 Feedback & inquiries: