Postgraduate Medicine

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Perioperative management of thyroid disease

Paul H. Pronovost & Kristin H. Parris

To cite this article: Paul H. Pronovost & Kristin H. Parris (1995) Perioperative management of
thyroid disease, Postgraduate Medicine, 98:2, 83-98, DOI: 10.1080/00325481.1995.11946030

To link to this article: https://doi.org/10.1080/00325481.1995.11946030

Published online: 05 Dec 2017.

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 Symposium

Third of four articles

on thyroid disorders
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a state of catecholamine excess and

Perioperative place the hyperthyroid patient at
increased risk during surgery.
management of PHYSIOWGIC EFFECrS--Hyper-
thyroidism induces a number
thyroid disease of changes that impose a burden
on the cardiovascular system.
Prevention of complications related to Thyrotoxicosis results in a hyper-
dynamic circulatory state marked
hyperthyroidism and hypothyroidism by increased cardiac output and
diminished reserve. Angina pec-
toris may be precipitated or wors-
ened, although actual myocardial
infarction is rare. Atrial fibrilla-
tion has been reported in up to
Preview 22o/o of thyrotoxic patients, com-
In discussions of the perioperative management of patients pared with 0.4o/o of the general
with thyroid disease, the wise axiom "an ounce of prevention population, 1 and it appears to be
is worth a pound of cure" remains especially applicable. Mor- more common among older men
tality rates with thyroid storm and myxedema coma, the most and persons who have triiodothy-
extreme complications, are still exceedingly high. In this arti- ronine (T3) thyrotoxicosis. The
cle, the authors discuss the physiologic effects of thyroid risk of arterial thromboembolism
disorders that adversely affect surgical risk. They also recom- apparently is increased to a
mend preventive measures. greater extent in those with thy-
rotoxicosis and atrial fibrillation
than in euthyroid patients with
Paul H. Pronovost, MD effective prophylaxis and therapy, atrial fibrillation. The culmina-
Kristin H. Parris, MD particularly for the most extreme tion of these abnormalities is a
complications-thyroid storm predisposition to high-output
•:• Thyroid disorders have varied and myxedema coma. congestive heart failure. Onere-
implications for patients who un- port documented the incidence
dergo surgical procedures. Often, Hyperthyroidism of congestive heart failure in thy-
the manifestations are elusive, Mainly as a result of its associ- rotoxic patients as 6o/o. 2
particularly in elderly patients. If ated metabolic and adrenergic- In addition to its adrenergic-
these conditions are to be man- stimulating properties, hyper- like effects, thyrotoxicosis induces
aged effectively, there must be a thyroidism (also referred to as a variety of metabolic (primarily
thorough understanding of such thyrotoxicosis) exerts a variety of catabolic) derangements. Para-
issues as physiologic abnormali- effects that may alter surgical risk doxically, a significant proportion
ties associated with thyroid dis- (table 1). 1-5 The adrenergic ef- of elderly patients may exhibit
eases, attendant surgical risk, and fects, in particular, may resemble anorexia, which exaggerates these
continued

VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE • PERIOPERATIVE MANAGEMENT OF THYROID DISEASE 83

 Thyroid storm remains the most significant
complication affecting surgical patients with
underlying hyperthyroidism.
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and metabolism of a number of

Table 1. Systemic effects of hyperthyroidism that increase surgical
risk'-• medications may be affected, re-
sulting in varied and unpre-
System Effect dictable drug levels or actions.
Thyroid storm is manifested
Metabolic Accelerated drug clearance as pyrexia, tachycardia, hemo-
Negative nitrogen balance
Hypoalbuminemia
dynamic instability, and changes
Impaired glucose tolerance in mental status. It remains the
Hypercalcemia most significant complication
Up-regulation of beta receptors affecting surgical patients with
underlying hyperthyroidism.
Cardiac Increased output
Increased total blood volume
Although the incidence has de-
Increased systemic vascular resistance creased with pharmacologic pro-
Increased chronotropism and inotropism phylaxis, mortality runs as high
Left ventricular hypertrophy as 40%.
Cardiomyopathy PERIOPERATIVE MANAGEMENT-
Angina pectoris
Atrial fibrillation
The form of perioperative man-
Congestive heart failure agement is determined by the
Thromboembolic events underlying cause of hyperthy-
roidism as well as the urgency for
Pulmonary Respiratory dysfunction surgery. When emergency surgery
Myopathy
is necessary in a patient with
Hematologic Anemia Graves' disease, measures should
Neutropenia be taken to help prevent thyroid
Thrombocytopenia storm (table 2). When thyroid
Increase in factor VIII storm is suspected (see page 86),
Decrease in vitamin K-dependent
factors (II, VII, IX, X) treatment should be instituted
immediately, before results of
Gastrointestinal Impaired drug absorption serum thyroid function tests are
available. In patients with mild
thyrotoxicosis, it is best to delay
elective surgery until the patient
abnormalities. Respiratory muscle effects on the coagulation system has attained a euthyroid state.
function may be impaired, partly are more difficult to predict and Very little is known about the
because of induced myopathy. In- of unclear significance. Increased
1
surgical risk in patients who
sulin metabolism may be affected bone resorption due to hyperthy- have hyperthyroidism that is not
and can lead to ketosis, particu- roidism may lead to hypercal- due to Graves' disease. Presum-
larly in a fasting or starved patient. cemia, the incidence of which ably, the risk is low, and elective
Hematologic derangements varies from 1Oo/o to 30%, de- surgery can proceed with the peri-
include anemia, neutropenia, and pending on the severity of thyro- operative administration of beta
thrombocytopenia. 4 The overall toxicosis.' In addition, absorption blockers, as discussed next. If

84 PERIOPERATIVE MANAGEMENT OF THYROID DISEASE • VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE

 Beta blockers are the mainstay of therapy for
patients with symptomatic thyrotoxicosis.
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beta blockers are contraindicated,
elective surgery again should be
delayed until a euthyroid state is
achieved. Because of limited
data, however, the most prudent
course may be to delay nonemer-
gency surgery until any form of
thyrotoxicosis has resolved.
Beta blockers-These are the
mainstay of therapy for patients
with symptomatic thyrotoxicosis.
Much of their usefulness comes
from their adrenergic antagonis-
tic properties, and many have the
added advantage of blocking pe-
ripheral conversion of thyroxine
(T4) to T 3 • While there are no
clear therapeutic differences
among the various agents, pro-
pranolol hydrochloride (Inderal)
is often cited as the drug of choice.
Use oflonger-acting agents, how-
ever, may improve patient com-
pliance.
In addition to being advanta-
geous in controlling peripheral
manifestations of hyperthyroid-
ism, beta blockers also exert pro-
tective effects through their anti-
arrhythmic properties and ability
to control ventricular rate. Be-
cause of their negative inotropic
effects, caution must be exercised
if an underlying cardiomyopathy
is suspected. Also, acute bron-
chospasm may be precipitated in
patients with underlying hyper-
active airway disease. However, if
a risk-benefit analysis warrants
their use, a beta 1-selective agent,
such as the very short-acting
VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE • PERIOPERATIVE MANAGEMENT OF THYROID DISEASE
Table 2. Recommended drug regimens for Graves' thyrotoxicosis
and thyroid storm*
Drug Graves' thyrotoxicosis Thyroid storm
Propranolol HCI 10 mg orally tid 1-1 0 mg/min IV
{lnderal)
Esmolol HCit 250 ~g/kg/min load,
(Brevi bloc) then 50 ~g/kg/min
Propylthiouracil 100 mg orally q6-8h 1,000 mg rectally
Methimazole 20 mg/day orally
(Tapazole)
Iodine Radioablationt 5 drops SSKI or
1 g sodium iodide I 131
IV q8-12h
Hydrocortisone If severe 100 mg q6h
SSKI, saturated solution of potassium iodide.
*Values represent dose at initiation of therapy. Final doses vary, depending on effect,
degree of thyrotoxicosis, or toxicity.
tDose should be increased 50 IJg/kg/min every 5 min to desired effect. Rates over
500 IJg/kg/min may be needed.'
:j:Recommendations vary, depending on patient age, sex, or other variables.
agent esmolol hydrochloride as prophylaxis against thyroid
(Brevibloc) should be used, as it storm. However, in patients with
allows rapid adjustment of dosage Graves' disease who are undergo-
to the desired degree of blockade. ing surgery, they should be used
In one case, 6 esmolol was found in conjunction with other agents,
to be effective after propranolol such as antithyroid drugs, iodine,
had failed. In patients with severe and glucocorticoids. Dosage is
thyrotoxicosis, larger doses of adjusted best according to the
beta blockers may be required, pulse rate, with the target being
partly because of accelerated under 80 beats per minute. It is
metabolism. important to continue therapy in
In patients with self-limited the postoperative period, because
forms of thyrotoxicosis, such as the threat of thyroid storm re-
subacute or painless thyroiditis, mains high during this time.
beta blockers may be used alone If the thyroid gland of a pa-
continued
85
 Thyrotoxicosis can be rapidly relieved by iodine,
which works immediately by inhibiting the
release of hormones from the hyperfunctioning
thyroid gland.
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tient with Graves' disease is re- or use of radiocontrast agents. Therapy may be discontinued
moved surgically, beta blockers Thioamides are not effective in after 7 to 14 days, although the
probably can be safely discontin- the management of thyroiditis decision to stop should be based
ued 2 days postoperatively. After unrelated to Graves' disease; in on the patient's clinical condition
nonthyroidal surgery, the duration these cases, preformed hormones rather than on the absolute dura-
of beta blockade is determined by are released from the gland, and tion of treatment. Some patients
the presence and degree of on- attempts to decrease hormone may have an exacerbation of thy-
going thyrotoxicosis. It also is im- synthesis are clinically less useful. rotoxicosis after iodine is discon-
portant to remember that many In thyrotoxic patients who are tinued.
of the metabolic effects of thyro- unable to receive antithyroid drugs Glucooorticoids-These agents
toxicosis (eg, interference with glu- (eg, those who have had previous may decrease the glandular re-
cose metabolism) are unaffected severe adverse reactions), the oral lease of thyroid hormones in pa-
or potentially made worse by beta radiocontrast agent ipodate so- tients with Graves' disease and
blockers, and continued vigilance dium (Bilivist, Oragrafin Sodium) protect against possible adrenal
IS necessary. may be used instead. While it is insufficiency, which may be asso-
Antithyroid drugs--If surgery not recommended for long-term ciated with thyrotoxicosis. 4 The
can be postponed in a patient control of patients with Graves' extent of their benefit in improv-
with Graves' disease, standard anti- disease, it may be of benefit to ing patient outcome remains
thyroid agents such as thioamide those in need of surgery. The op- unclear, however.
derivatives (ie, propylthiouracil timal dosage is 500 mg a day Anesthetics-Studies examin-
and methimazole [Tapazole]) orally for 5 days, although even ing the effects of various anes-
should be started. Although pro- one dose may be of benefit to thetics and comparing general to
pylthiouracil has the added ad- those who require emergency spinal anesthesia in hyperthyroid
vantage of blocking peripheral procedures. 7 patients have had conflicting re-
conversion ofT4 toT,, methima- Iodine-Thyrotoxicosis can be sults. Drugs such as atropine
zole has a longer half-iife, and its relieved rapidly by iodine, which sulfate and other antiparasympa-
use may improve patient compli- works immediately by inhibiting thetic agents should be avoided,
ance. the release of hormones from the because they may increase the
Clinical improvement can be hyperfunctioning thyroid gland. degree of sympathetic activity.
seen after a few weeks and usually Because iodine is the precursor Epidural blockade may be used
precedes biochemical improve- of new hormone synthesis, it in hyperthyroid patients if indi-
ment. A longer period of therapy should be used in combination cated. 8 '9 Decisions regarding the
may be needed for those who with antithyroid drugs so that type of anesthesia and particular
have received large quantities of little of the administered iodine is agents to be used belong in the
iodine from radioiodine ablation oxidized and organified to form hands of the anesthesiologist.
new hormone. Propylthiouracil, Thyroid stonn-As noted, this
therefore, is given about an hour is the most feared complication
Paul H. Pronovost, MD before the iodine is administered. in hyperthyroid patients under-
Kristin H. Parris, MD Either an oral saturated solution
Drs Pronovost and Parris are assistant
going surgery. It develops most
professors, section of general internal
of potassium iodide (SSKI), Lugol's commonly during operation and
medicine, Ternple University School of solution, or intravenous sodium in the ensuing 18 hours. The
Medicine, Philadelphia. iodide (Iodotope) may be used. presentation is usually abrupt
continued on page 96
86 PERIOPERATIVE MANAGEMENT OF THYROID DISEASE • VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE
 It has been estimated that 0.5% to 0.8% of the
total adult population is hypothyroid; the incidence
in females is about 10 times that in males.
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and may be confused easily with
other entities, such as malignant
hyperthermia, 10 neuroleptic ma-
lignant syndrome, sepsis, delirium
tremens, pheochromocytoma,
drug intoxication, and acute psy-
chiatric illness.
Tachyarrhythmias, usually sinus
tachycardia, are frequent. Atrial
fibrillation is often seen, and
larger doses of digoxin (Lanoxin)
are needed to control the ven-
tricular response. Cardioversion
usually is not successful as long
as thyrotoxicosis persists. Hyper-
glycemia, leukocytosis, diarrhea,
and evidence of adrenal insuffi-
ciency may occur.
Treatment must begin as soon
as the diagnosis is entertained se-
riously and, as noted before, should
not be delayed while awaiting
laboratory markers of thyrotoxi-
cosis; untreated thyroid storm is
associated with high mortality.
Intravenous propranolol should
be started (table 2). Associated
congestive heart failure due to
thyrotoxicosis is not an absolute
contraindication to beta block-
ade, but the latter should be pre-
ceded by administration of di-
goxin. Propylthiouracil, 1,000 mg,
should be given rectally, followed
in 1 hour by iodine therapy. Stress
doses of corticosteroids may be of
benefit. Invasive hemodynamic
monitoring with a pulmonary
artery catheter is useful and can
guide the need for diuretics or
volume expansion. Frequent mea-
surements of serum electrolytes,
96 PERIOPERATIVE MANAGEMENT OF THYROID DISEASE • VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE
glucose, and calcium are neces-
sary. The degree of oxygenation
should be monitored with arte-
rial blood gas studies, and an ar-
terial line should be considered
strongly.
Other aggressive supportive
care should be given as indicated
and may include antipyretics,
cooling blankets, and vitamin
supplements. Aspirin should be
avoided as an antipyretic because
it may displace T 4 from its bind-
ing proteins. 4
Other precipitating factors
of thyroid storm, such as sepsis,
should be sought and also treated
aggressively. Plasmapheresis or
peritoneal dialysis to remove ex-
cess circulating thyroid hormones
is rarely needed.
Hypothyroidism
It has been estimated that 0.5%
to 0.8% of the total adult popu-
lation is hypothyroid. The inci-
dence in females is about 10 times
that in males. Most cases are iat-
rogenic, resulting from treatment
with radioactive iodine or surgi-
cal thyroidectomy. In addition,
drug-induced hypothyroidism,
such as that from lithium or
amiodarone hydrochloride (Cor-
darone), is being increasingly rec-
ognized.
PHYSIOWGIC EFFECfS-The
signs and symptoms of hypothy-
roidism vary with the degree of
deficiency but are often subtle
and protean, particularly in the
elderly. The only physical find-
ings that have a high statistical
correlation with hypothyroidism
are delayed ankle reflexes, hoarse
voice, and dry skin. 11 While pre-
sentations may vary, there is no
organ system that ultimately goes
unaffected (table 3). 11 - 16
The risks in patients with hypo-
thyroidism undergoing surgery
also vary and can be stratified by
the degree of deficiency. A retro-
spective clinical studi 6 showed
that certain surgical complications
were more frequent in patients
with severe hypothyroidism. Com-
plications included intraoperative
hypotension, perioperative gastro-
intestinal hypomotility, neuro-
psychiatric disturbance, and lack
of postoperative fever. However,
no significant increase in com-
plications was demonstrated in
those with mild to moderate hy-
pothyroidism. Thus, when possi-
ble, surgery should be postponed
in patients with severe hypothy-
roidism to permit at least partial
thyroid hormone replacement;
patients with less severe hypothy-
roidism can probably undergo
surgery safely. On the basis of the
available literature, we designate
mild to moderate hypothyroid-
ism as a serum thyrotropin (TSH)
level of 10 to 50 f.LU/mL and se-
vere hypothyroidism as a TSH
level over 60 f.LU/mL. Because of
the considerable overlap in TSH
values given in the literature, the
general clinical assessment should
be factored into the preoperative
evaluation.
 Overtly hypothyroid or myxedematous patients
in need of urgent surgery require aggressive
preoperative thyroid replacement.
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PERIOPERATIVE MANAGEMENT-
The average daily replacement Table 3. Systemic effects of hypothyroidism that increase
surgical risk" ,.
dose oflevothyroxine sodium in
hypothyroid patients is 75 to System Effect
150 f.,Lg. In patients who are re-
ceiving adequate replacement Metabolic Hypothermia
and are clinically euthyroid, thy- Impaired drug clearance
Hypoglycemia
roid hormone supplements can
be withheld on the morning of Integumentary Easy bruising
surgery and restarted postopera-
tively once the patient is eating. Cardiac Pericardia! effusion
Impaired output
This is possible because levothy-
Increased systemic vascular resistance
roxine has a long half-life of? Decreased blood volume
days. If needed, it can be admin- Impaired baroreceptor response
istered parenterally, usually at half Bradyarrhythmias
the oral dose. Because of the high Electrocardiographic abnormalities (decreased
voltages, T-wave flattening and inversion)
expense of parenterallevothyrox-
ine, the oral route should be used Pulmonary Laryngeal myxedema
whenever possible. Macroglossia
Overtly hypothyroid or myx- Decreased breathing capacity
edematous patients in need of ur- Impaired Dlc0
Impaired hypoxic and hypercapnic respiratory
gent surgery require aggressive drive
preoperative thyroid replacement; Pleural effusions
300 to 500 f.,Lg is given intra-
venously, then 100 f.,Lg daily. Gastrointestinal Decreased peristalsis
Hydrocortisone, 100 to 300 mg Ascites
Gastrointestinal bleeding
intravenously every 8 hours,
should be given concurrently, Hematologic Normochromic normocytic anemia
because these patients may lack Decreased platelet adhesiveness
the adrenal reserve that is neces- Decrease in clotting factors
sary to respond to an acute in-
Renal Abnormal free water clearance
crease in basal metabolic rate. Hyponatremia
Swan-Ganz catheters and arterial
lines should be used to monitor Central nervous Confusion
hemodynamic status. Psychosis
Older patients-For older pa- Stupor
Coma
tients in whom occult coronary Impaired cerebral blood flow
artery disease is a concern, a less
aggressive approach to replace-
ment therapy should be adopted
Dlc0 , diffusion capacity of carbon monoxide.
whenever possible. Levothyroxine
should be started at an initial
continued
VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE • PERIOPERATIVE MANAGEMENT OF THYROID DISEASE 97
 Despite aggressive treatment, myxedema
coma has a mortality rate of 50%.
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daily dose of 25 j.Lg and then
increased by 25 j.Lg every 2 to
3 weeks until a full replacement
dose is reached. Close observa-
tion for symptoms of chest pain
and arrhythmias on electrocar-
diographic monitoring is recom-
mended. If a patient with hypo-
thyroidism and known coronary
artery disease is to have coronary
revascularization, thyroid replace-
ment should be postponed until
after the procedure.
Myxedema coma-Despite
aggressive treatment, this medical
emergency has a mortality rate
of 50%. It is characterized by
progressive stupor, hypothermia,
hypoventilation, hypoglycemia,
and hyponatremia. Regardless
of comorbid conditions, manage-
ment should include replacing
the total thyroid deficit, which
usually requires 300 to 500 j.Lg
of levothyroxine, followed several
days later by average daily re-
placement (7 5 to 150 j.Lg a day).
Administering only the average
daily requirement from the onset
of therapy without replacing the
depleted pool appears to be in-
adequate and results in higher
mortality. In this situation, em-
pirical coadministration of ni-
trates may be of benefit. Corti-
costeroid replacement is also
recommended, as described pre-
viously. Prophylaxis has the great-
est impact on averting the poor
outcome associated with this
condition.
98 PERIOPERATIVE MANAGEMENT OF THYROID DISEASE • VOL 98/NO 2/AUGUST 1995/POSTGRADUATE MEDICINE
Summary
Patients with underlying thyroid
disease who are in need of sur-
gery present a particular chal-
lenge to the surgeon responsible
for their care and to the medical
consultant who must offer clin-
ical guidance. Often, underlying
thyroid disease is difficult to
detect clinically, because signs
and symptoms of disease are
varied or subde. Furthermore,
those with known disease who
are receiving a seemingly stable
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-®
Earn credit on this article.
See CME Quiz.
Mailing address: Kristin H. Parris,
MD, Department of Medicine, Tem-
ple University School of Medicine,
3401 N Broad St, Room 757 PP,
Philadelphia, PA 19140.
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