Mon, 12/24/2007 - 17:34 — oxygen Hyperthyroidism Listen to Audio Clinical causes Clinical manifestations Diagnosis Treatment Preoperative management Intraoperative management Postoperative mangement Clinical causes: -Graves Disease -exogenous administration -thyroiditis -toxic multinodular goiter -adenoma of thyroid -tumor of pituitary Clinical manifestations: -weight loss -muscle weakness -nervousness -heat intolerance -diarhea -reflex (hyper-reflexia) Diagnosis: Throid Function Test: -increased T3 -increased T4 (bound and unbound) -decreased TSH Treatment: Medical treatment -propylthiouracil -methimazole -sodium iodide -potassium -propranolol -radioactive iodine (not for pregnant females) Surgical treatment -subtotal thyroidectomy Indication: -large toxic multinodular goiter -solitary toxic adenoma Preoperative management Elective surgery: -euthryoid with medical treatment -normal thyroid function test -resting heart rate < 85 bpm -continue antithyroid medications till a.m of surgery Emergency surgery: -attempt for CVS stability with esmolol infusion Intraoperative management Induction: -induction agent of choice : thiopental may have an exaggerated hypotensive response to induction due to: -hypovolemia -vasodilated Intubation: intubate patient when deeply anesthetized to avoid: -tachycardia -hypertension -ventricular dysrhythmia Systemic precautions: -ophthalmology: exopthalmus: therefore avoid corneal abrasions -airway: avoid kinking, compression or obstruction of ETT: may require armored ETT -thyroid mass: head elevation approx 15 - 20 degree to promote venous drainage and reduce amount of bleeding -cardiac: avoid tachycardia, hypertension, ventricular dysrhythmias -hepatic: increased drug metabolism therefore more prone to hepatic injury ex. halothane hepatitis -renal: may be prone to renal toxicity ex. enflurane -NMJ: hyperthyroidism may be associated myopathies, myasthenia gravis Postoperative management: Observe for potential postoperative complications: -thyroid storm -recurrent laryngeal nerve (RLN) palsy -hematoma -hypoparathyroidism -pneumothorax Thyroid storm: -change in mental status (agitation, delirium, coma) -tachycardia (treat with esmolol infusion or propranolol 0.5 mg IV increments until heart rate is less than 100bpm) -hyperpyrexia (treat with cooling blanket) recurrent laryngeal nerve palsy: acute -unilateral: hoarseness -bilateral: stridor, aphonia, flacid paralysis adduction of vocal cords Hematoma: -may create tracheal/airway compression and obstruction

Tue, 12/25/2007 - 11:11 — oxygen Hypothyroidism Listen to Audio Clinical causes Clinical manifestations Diagnosis Treatment Preoperative management Intraoperative management Postoperative management Clinical causes: -Hashimotos thyroiditis -iodine deficiency -radioactive iodine -antithyroid medications -thyroidectomy -secondary hypothyroidism Clinical manifestations -weight gain -cold intolerance -muscle fatigue -lethargy -constipation -reflex decreased (hyporeflexia) -depression Diagnosis: Primary hypothyroidism: -decreased T3 -decreased T4 -increased TSH Secondary hypothyroidism:

levothyroxine 50 mg q day Preoperative management: Elective surgery: -thyroid hormone level should be therapeutic Emergency surgery: give thyroid hormone prior to procedure in patients with: -uncorrected severe hypothyroidism T4< 1mg/dL -myxedema coma Premedication: -may not be required due to the sedative nature of the disease (lethargy. depression) -may be more prone to opiod induced respiratory depression Intraoperative management: induction: ketamine may be considered induction agent of choice Airway: may be difficult intubation due to large tongue CNS: same MAC requirements CVS: senstive to cardiodepressant effects of volatile anesthetics due to: -decreased intravascular volume therefore decreased preload -blunted baroreceptor response theferefore decreased HR -overall decreased cardiac output Other possible intraoperative complications: -hypoglycemia -hyponatremia -hypothermia -large tongue for difficult ventilation/intubation Postoperative management May have delayed emergence/recovery from GA due to: -hypothermia -respiratory depression -delayed/slowed drug biotransformation *therefore may require prolonged mechanical ventilation *ketorolac may be preferred to opiod analgesia due to less risk of drug induced respiratory depression .-decreased T3 -decreased T4 -decreased TSH Treatment: Oral replacement: -physiological effect within few days -clinical improvement within several weeks Myxedema/emergency: -loading dose: levothyroxine 300 .500mg -maintenence doses: ex.

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