Nonthyroid Surgery in The Patient With Thyroid Disease - UpToDate

Nonthyroid surgery in the patient with thyroid disease - UpToDate 8/11/17 20(21
Authors: Ellen F Manzullo, MD, FACP, Douglas S Ross, MD

Section Editor: David S Cooper, MD
Deputy Editor: Jean E Mulder, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2017. | This topic last updated: Jun 21, 2017.
INTRODUCTION — Thyroid disease is common; the prevalence is higher in women and with increasing age.
Thus, a significant number of patients who are undergoing surgery may have concomitant thyroid disease.
Although most patients with well-compensated thyroid disease do not need special consideration prior to
surgery, patients who have a newly diagnosed thyroid disorder around the time of surgery require a discussion
of the risks and benefits of proceeding with surgery.
The issues surrounding thyroid disease in patients undergoing nonthyroid surgery are discussed here. The
management of patients with hyperthyroidism undergoing thyroid surgery is reviewed separately. (See "Surgical
management of hyperthyroidism", section on 'Preoperative preparation'.)
IS PREOPERATIVE MEASUREMENT OF TSH NECESSARY? — Despite the relatively high prevalence of

thyroid disease in the general population, we believe there is no need to screen for thyroid disease during the
preoperative medical consultation. (See "Preoperative medical evaluation of the adult healthy patient".)
However, if the history and physical examination are suggestive of thyroid disease, it is reasonable to try to
make the diagnosis since it can have effects upon perioperative management. (See "Diagnosis of
hyperthyroidism" and "Diagnosis of and screening for hypothyroidism in nonpregnant adults".)
For patients with known thyroid disease taking thyroid medication, monitoring of thyroid function on at least an
annual basis is part of routine care. Adjustments in dosing are made as needed to maintain euthyroidism. In
these patients with well-compensated thyroid disease, we and others believe that additional testing prior to
surgery is unnecessary, as long as the patient is on a stable dose of medication and euthyroidism was
documented within the past three to six months. (See "Treatment of primary hypothyroidism in adults", section
on 'Dose and monitoring'.)
HYPOTHYROIDISM
Clinical manifestations that may impact perioperative outcome — Hypothyroidism affects many bodily
systems that might influence perioperative outcome [1] (see "Clinical manifestations of hypothyroidism"):
● The systemic hypometabolism that is associated with hypothyroidism results in a decrease in cardiac
output that is mediated by reductions in heart rate and contractility. (See "Cardiovascular effects of
hypothyroidism".)
● Hypoventilation occurs because of respiratory muscle weakness and reduced pulmonary responses to
hypoxia and hypercapnia. (See "Respiratory function in thyroid disease", section on 'Hypothyroidism'.)
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● Decreased gut motility results in constipation and ileus.
● A variety of metabolic abnormalities can occur in hypothyroidism, including hyponatremia due to a

reduction in free water clearance, reversible increases in serum creatinine, and reduced clearance of some
drugs (eg, antiepileptics, anticoagulants, hypnotics, and opioids). Reduced clearance of vitamin K-
dependent clotting factors, however, results in higher warfarin requirements during hypothyroidism and
falling requirements during treatment with thyroid hormone.
● Patients with hypothyroidism have a decrease in red blood cell mass and a normochromic, normocytic
anemia.
Defining the severity of hypothyroidism — Surgical outcomes vary with the degree of underlying
hypothyroidism (see 'Surgical outcomes' below). In addition, one approach to management is to base
therapeutic decisions on the severity of hypothyroidism (see 'Management' below). However, the definitions of
mild, moderate, and severe hypothyroidism can be vague, and definitions may differ between experts or
studies. We find the following definitions useful:
● Severe hypothyroidism – Includes patients with myxedema coma; with severe clinical symptoms of
chronic hypothyroidism such as altered mentation, pericardial effusion, or heart failure; or those with very
low levels of total thyroxine (T4) (eg, less than 1.0 mcg/dL) or free T4 (eg, less than 0.5 ng/dL) [2,3].
● Moderate hypothyroidism – Includes all other patients with overt hypothyroidism (elevated thyroid-
stimulating hormone [TSH], low free T4) without the features of severe hypothyroidism.
● Mild hypothyroidism – Includes patients with subclinical hypothyroidism, defined biochemically as a

normal serum free T4 concentration in the presence of an elevated serum TSH concentration.
Surgical outcomes — Observational studies evaluating surgical outcomes in patients with subclinical or overt
hypothyroidism generally show few adverse effects in patients with mild (subclinical) or moderate
hypothyroidism, but adverse outcomes increase with the severity of hypothyroidism.
● Mild (subclinical) hypothyroidism – There are few data on surgical outcomes in subclinical hypothyroid
patients. In a prospective study comparing postoperative outcomes (after coronary artery bypass grafting
[CABG]) in patients with known preoperative subclinical hypothyroidism (elevated TSH with normal free
T4) and euthyroid patients, there were no significant differences in major adverse cardiovascular events or
other outcomes (wound problems, mediastinitis, leg infection, respiratory complications) [4]. Similar results
were reported in a study of outcomes after percutaneous transluminal coronary angioplasty [5].
● Moderate overt hypothyroidism – Several studies have investigated the safety of general anesthesia
and surgery in patients with untreated or inadequately treated hypothyroidism [2,6,7]. Surprisingly few
adverse effects were reported, although the hypothyroid patients had a higher frequency of peri- and
postoperative ileus, hypotension, hyponatremia, and central nervous system dysfunction than did the
euthyroid patients. They also had less fever during serious infections and increased sensitivity to
anesthesia and opiate pain medications.
As examples:
• One study investigated anesthetic and surgical outcomes in 59 hypothyroid patients and 59 paired
euthyroid controls [2]. There were no differences between the groups in duration of surgery or
anesthesia, lowest temperature and blood pressure recorded during surgery, need for vasopressors,
time to extubation, fluid and electrolyte imbalances, incidence of arrhythmias, pulmonary and
myocardial infarction, sepsis, need for postoperative respiratory assistance, bleeding complications, or
time to hospital discharge.
• The second study investigated perioperative complications in 40 patients with mild to moderate
hypothyroidism compared with 80 matched controls [6]. The hypothyroid patients had more
intraoperative hypotension in noncardiac surgery and more heart failure in cardiac surgery. They also
had more postoperative gastrointestinal and neuropsychiatric complications and were less likely to
mount a fever with infection. However, in this study, there were no differences in perioperative blood
loss; duration of hospitalization; or the prevalences of perioperative arrhythmia, hypothermia,
hyponatremia, delayed anesthetic recovery, abnormal tissue integrity, impaired wound healing,
pulmonary complications, or death.
● Severe hypothyroidism – Older case studies in the anesthesia literature reported intraoperative
hypotension, cardiovascular collapse, and extreme sensitivity to opioids, sedatives, and anesthesia in
undiagnosed patients with more severe hypothyroidism, including myxedema [8,9]. In some case reports,
myxedema coma is described as a rare postoperative complication in patients with unrecognized severe
hypothyroidism [10-13]. This represents a medical emergency with a high mortality rate. The hallmarks of
myxedema coma are decreased mental status and hypothermia, but hypotension, bradycardia,
hyponatremia, hypoglycemia, and hypoventilation are often present as well. (See "Myxedema coma".)
Management — In the absence of clinical trial data, the management of patients with recently diagnosed
hypothyroidism who require surgery is based upon observational data and clinical experience. We base
therapeutic decisions on the severity of hypothyroidism.
Subclinical hypothyroidism — We suggest not postponing surgery in patients with subclinical

hypothyroidism (elevated serum TSH, normal free T4). This suggestion is based upon the studies in patients
undergoing CABG and percutaneous transluminal coronary angioplasty (PTCA) described above [4,5]. (See
'Surgical outcomes' above.)
The treatment of subclinical hypothyroidism is reviewed separately. (See "Subclinical hypothyroidism in

nonpregnant adults", section on 'Management'.)
Moderate (overt) hypothyroidism — Our approach in patients with moderate hypothyroidism is based
upon whether the surgery is urgent or elective and, in addition, upon the retrospective studies cited above [2,6].
(See 'Surgical outcomes' above.)
● Elective surgery – We suggest postponing elective surgery until the euthyroid state is restored.
● Urgent surgery – We suggest that patients with moderate, overt hypothyroidism undergo urgent surgery
without delay, with the knowledge that minor perioperative complications might develop.
When a diagnosis of moderate hypothyroidism is made preoperatively, thyroid hormone replacement should be
initiated as soon as the diagnosis is made. Generally, young patients are started on close to full replacement
doses of levothyroxine (T4) (1.6 mcg/kg daily), while older patients or patients with cardiopulmonary disease
are started on 25 to 50 mcg daily with an increase in dose every two to six weeks. (See "Treatment of primary
hypothyroidism in adults", section on 'Initial dose'.)
Severe hypothyroidism — There is a lack of outcome data to direct the care of severely hypothyroid
patients in the perioperative period. These patients should be considered high risk.
● Elective surgery – Elective surgery should be delayed until hypothyroidism has been treated.
● Urgent surgery – If emergency surgery must be performed in a patient with severe hypothyroidism, the
patient should be treated as soon as the diagnosis is made. If there is concern about existing or
precipitating myxedema coma (table 1), we prefer to treat patients with both triiodothyronine (T3) and T4 to
rapidly normalize thyroid function (see "Myxedema coma"):
- T4 is given in a loading dose of 200 to 300 mcg intravenously (IV) followed by 50 mcg daily.
- T3 is given simultaneously in a dose of 5 to 20 mcg IV followed by 2.5 to 10 mcg every eight

hours depending upon the patient's age and coexistent cardiac risk factors.
Use of an arterial line and Swan-Ganz catheter should be considered if cardiopulmonary disease exists.
• Consider adrenal insufficiency – Rarely, Addison's disease will be present in a patient with primary
hypothyroidism due to Hashimoto's thyroiditis. In addition, patients with central (secondary)
hypothyroidism may have inadequate pituitary adrenal reserve as euthyroidism is restored. If the
status of the pituitary adrenal axis is uncertain and deficiency is considered likely, patients should be
given stress doses of corticosteroids until the integrity of the axis is ascertained. If the clinical situation
permits (ie, surgery can be delayed for an hour), a cosyntropin stimulation test should be performed
prior to administering steroids. If the results of the cosyntropin test are normal, stress steroids are not
needed and can be discontinued if already given. (See "Evaluation of the response to ACTH in
adrenal insufficiency", section on 'ACTH stimulation tests'.)
• Postoperative concerns – In the postoperative period, the patient's fluid and electrolyte status,
especially the serum sodium, will need to be followed closely. In addition, a high index of suspicion for
the development of an ileus, neuropsychiatric symptoms, and an infectious process without the
presence of a fever is required.
Cardiovascular surgery — Patients with hypothyroidism who are scheduled to undergo cardiovascular
interventions or surgery require special consideration. The risk of precipitating or worsening unstable coronary
syndromes with thyroid hormones conflicts with the concern that untreated hypothyroidism might worsen heart
failure or hypotension in the cardiac surgical patient.
Retrospective and prospective studies of cardiac patients found no adverse outcomes in cardiac patients with
mild to moderate hypothyroidism who had cardiac surgery or catheterization without thyroid replacement [7,14].
In a prospective study comparing postoperative outcomes in patients with known preoperative subclinical
hypothyroidism (elevated TSH with normal free T4) and euthyroid patients, there were no significant differences
in major adverse cardiovascular events or other outcomes (wound problems, mediastinitis, leg infection,
respiratory complications) [4].
Angina is not an absolute contraindication to thyroid hormone replacement if the patient has symptomatic
hypothyroidism. In patients with angina treated medically, the dose of T4 should begin with 25 micrograms/day
and is increased 25 micrograms every two to six weeks, depending upon response. Presently, most patients
with angina have coronary artery revascularization first, and T4 is prescribed afterwards [1]. In most patients,
angina has resolved after revascularization and before T4 has been prescribed, allowing the safe initial
administration of a T4 dose that is approximately 50 to 75 percent of the full replacement dose based on body
weight and adjusted four to six weeks later. (See "Treatment of primary hypothyroidism in adults", section on
'Older patients or those with coronary heart disease'.)
Preexisting hypothyroidism — Patients with a history of hypothyroidism receiving chronic T4 therapy who
undergo surgery and are unable to eat for several days do not need to be given T4 parenterally. If oral intake
cannot be resumed in five to seven days, then T4 should be given IV or intramuscularly. The dose should be
approximately 70 to 80 percent of the patient's usual oral dose because that is approximately the fraction of oral
T4 that is absorbed. We typically give 80 percent. (See "Treatment of primary hypothyroidism in adults", section
on 'Surgical patients'.)
HOSPITALIZED/SERIOUSLY ILL PATIENTS WITH SUSPECTED HYPOTHYROIDISM — Assessment of

thyroid function in hospitalized or seriously ill patients can be difficult. Patients who are seriously ill often have
abnormal thyroid function tests that may or may not be clinically significant [15]. These patients need to be
distinguished from those who have clinically significant thyroid dysfunction. In general, thyroid function should
not be assessed in seriously ill patients unless there is a strong suspicion of thyroid dysfunction. When thyroid
dysfunction is suspected in critically ill patients, measurement of serum TSH alone is not appropriate for the
evaluation of thyroid function. Instead, measurement of TSH, total T4, free T4, T3, and sometimes reverse T3 is
necessary. (See "Thyroid function in nonthyroidal illness".)
The changes in thyroid function during critical illness include the following (figure 1):
● The majority of hospitalized patients have a low serum T3 concentration. Abnormalities in the T3
concentration have been noted in patients undergoing elective or emergency surgery, independent of the
type of anesthesia.
● From 15 to 20 percent of hospitalized patients and up to 50 percent of patients in intensive care units have
low serum T4 concentrations (low T4 syndrome).
● The serum TSH concentration may also be low.
Previously, these patients were thought to be euthyroid, and the term "euthyroid sick syndrome" was used to
describe the laboratory abnormalities. The term "nonthyroidal illness" is now preferred since experimental data
suggest that these patients develop acquired transient central hypothyroidism [16]. However, these changes
may be adaptive rather than pathological in nature, and there is no evidence of benefit and some risk of harm
by giving thyroid hormone to patients with nonthyroidal illness who have low serum T4 or T3 concentrations.
● Distinguishing nonthyroidal illness from primary hypothyroidism – In most critically ill patients with
moderate or severe primary hypothyroidism, serum TSH will be well above the normal range (>20 mU/L) in
association with a low free T4, and further management is as described above. (See 'Moderate (overt)
hypothyroidism' above and 'Severe hypothyroidism' above.)
● Distinguishing nonthyroidal illness and central hypothyroidism – Patients with severe nonthyroidal
illness may have transient adaptive central hypothyroidism, and in these patients, it may be difficult to
distinguish nonthyroidal illness from true central hypothyroidism, particularly in patients with a history of
hypothalamic or pituitary disease.
• Elective surgery – In this setting, nonurgent surgeries should be postponed, and clinical status and
thyroid function tests (TSH, free T4) should be monitored every four to six weeks. In patients with
transient central hypothyroidism due to nonthyroidal illness, thyroid tests should return to normal,
whereas the thyroid test abnormalities will persist in patients with true central hypothyroidism. (See
"Central hypothyroidism".)
• Urgent surgery – If the diagnosis of hypothyroidism is in doubt in a critically ill patient (because of the
difficulty assessing thyroid function in this population) and surgery cannot be postponed, we treat with
thyroid hormone replacement in the pre- and perioperative periods if there is clinical evidence to
suggest a diagnosis of moderate to severe hypothyroidism (eg, bradycardia and hypothermia along
with slow mentation, puffy face, a possible personal or strong family history of thyroid disease, or
personal history of hypothalamic or pituitary disease or cranial irradiation).
In the absence of suspected myxedema coma, repletion should be cautious, beginning with
approximately half the expected full replacement dose of T4 (0.8 mcg/kg for young patients and 25 to
50 mcg daily for older patients or patients with cardiopulmonary disease). We measure TSH and free
T4 after four to six weeks, and further treatment decisions are based upon the results. In a patient with
suspected central hypothyroidism, biochemical assessment of the pituitary adrenal axis should be
performed, as described above. (See 'Severe hypothyroidism' above.)
HYPERTHYROIDISM
Clinical manifestations that may impact perioperative outcome — As with hypothyroidism, hyperthyroidism
affects many bodily systems that might influence perioperative outcome (see "Overview of the clinical
manifestations of hyperthyroidism in adults"):
● Patients with hyperthyroidism have an increase in cardiac output, due both to increased peripheral oxygen
needs and increased cardiac contractility. Heart rate is increased, pulse pressure is widened, and
peripheral vascular resistance is decreased. (See "Cardiovascular effects of hyperthyroidism".)
● Atrial fibrillation occurs in approximately 8 percent of patients with hyperthyroidism and is more common in
older patients [17].
● Even subclinical hyperthyroidism is associated with increased rates of atrial ectopy and a threefold
increased risk of atrial fibrillation. (See "Subclinical hyperthyroidism in nonpregnant adults", section on
'Atrial fibrillation'.)
● Dyspnea may occur for a variety of reasons, including increased oxygen consumption and carbon dioxide
(CO2) production, respiratory weakness, and decreased lung volume. (See "Respiratory function in thyroid
disease", section on 'Hyperthyroidism'.)
● Weight loss is due primarily to increased calorigenesis and secondarily to increased gut motility and the
associated hyperdefecation and malabsorption; these changes can cause the patient to be malnourished.
Management — There are few published studies evaluating the risks of nonthyroid surgery in hyperthyroid
patients. We base our management decisions on the severity of the hyperthyroidism.
● Subclinical hyperthyroidism is defined as a low TSH with normal free T4 and T3

● Overt hyperthyroidism is defined as a suppressed TSH with elevated free T4 and/or T3 concentrations
Subclinical hyperthyroidism — In our experience, patients with subclinical hyperthyroidism can typically
proceed with elective or urgent surgeries. Unless contraindicated, we typically administer a beta blocker (eg,
atenolol 25 to 50 mg daily) preoperatively to older patients (>50 years), or younger patients with cardiovascular
disease, especially atrial arrhythmias, and taper after recovery. (See "Beta blockers in the treatment of
hyperthyroidism".)
Overt hyperthyroidism — In patients with untreated or poorly controlled hyperthyroidism, an acute event
such as surgery can precipitate thyroid storm, a potentially life-threatening condition. (See 'Thyroid storm'
below.)
● Elective surgery – We suggest postponing all elective surgeries in patients with newly discovered, overt
hyperthyroidism until the patient has achieved adequate control of their thyroid condition (usually three to
eight weeks).
● Urgent surgery – For overtly hyperthyroid patients in whom surgery cannot be postponed, preoperative
treatment of hyperthyroidism should be initiated as soon as possible. (See 'Preoperative preparation for
urgent surgery' below.)
In addition, the hyperthyroid patient requiring urgent surgery should be evaluated for possible
cardiopulmonary disease, and the patient should be monitored for the possible development of
arrhythmias, cardiac ischemia, and congestive heart failure [18]. Use of an arterial line and pulmonary
artery catheter should be considered if cardiopulmonary disease exists. In the postoperative period,
hyperthyroid patients are at increased risk of prolonged intubation due to increased basal oxygen
consumption and respiratory muscle weakness.
Preoperative preparation for urgent surgery — Preoperative preparation typically includes beta
blockers and, in patients with Graves' disease or toxic adenoma/multinodular goiter (MNG), thionamides. While
thionamides alone are sufficient to achieve euthyroidism in approximately three to eight weeks, we suggest
adding iodine (potassium iodide solution, SSKI, one to five drops three times daily) at least one hour after
thionamides are administered, if hyperthyroidism is severe and the need for surgery is urgent [19].
Beta blockers — In the absence of contraindications, we administer a beta blocker preoperatively to

patients with overt hyperthyroidism undergoing urgent nonthyroid surgery. The longer-acting beta blockers (eg,
atenolol) are preferred in patients who are candidates for therapy because an oral dose taken one hour before
surgery will usually maintain adequate beta blockade until the patient is able to take oral medications
postoperatively [20].
● We typically start with atenolol 25 to 50 mg daily and increase the dose as needed to maintain the pulse
rate below 80 beats/minute; up to 200 mg daily may be needed for the symptomatic treatment of
hyperthyroidism and control of tachycardia.
● Intravenous (IV) propranolol (0.5 to 1 mg over 10 minutes followed by 1 to 2 mg over 10 minutes every few
hours) can be used to control fever, hypertension, and tachycardia intraoperatively [21,22].
● Beta blockers should be continued until the patient's thyroid disease is under control.
Patients with relative contraindications to beta blockade may better tolerate beta-1-selective agents, such as
atenolol or metoprolol, although even these drugs cannot be considered completely safe in patients with
asthma or chronic obstructive pulmonary disease. (See "Treatment of hypertension in asthma and COPD",
section on 'Beta blockers'.)
Calcium channel blockers can also be used for rate control in patients in whom beta blockers are
contraindicated.
There are few data on the benefits of beta blocker administration to hyperthyroid patients undergoing
nonthyroid surgery [23,24]. In hyperthyroid patients undergoing thyroid surgery, beta blockers administered
preoperatively effectively control the clinical manifestations of hyperthyroidism and can be used for preoperative
preparation of the hyperthyroid patient who cannot take thionamides or who needs urgent surgery, and there is
insufficient time to render the patient euthyroid with thionamides [25-27]. As an example, in a randomized trial
of methimazole versus metoprolol in 30 patients with newly diagnosed and untreated hyperthyroidism
undergoing thyroid surgery, there was no difference in anesthesiologic or cardiovascular complications during
surgery or in complications postsurgery [25]. The results of this trial suggest that serious perioperative
complications are low in patients undergoing thyroid surgery who are treated preoperatively with beta blockers.
However, case reports have documented the development of thyroid storm after surgery even when beta
blockers have been used [28]. (See "Beta blockers in the treatment of hyperthyroidism".)
Thionamides — If hyperthyroidism is associated with an elevated radioiodine uptake (eg, toxic

adenoma or MNG), thionamides should be initiated with the aim of controlling hyperthyroidism in the
postoperative period. Thionamides block de novo thyroid hormone synthesis but have no effect upon the
release of preformed hormone from the thyroid gland and will therefore not have a significant effect on thyroid
hormone levels over only a few preoperative days.
● Methimazole (10 mg two to three times daily or 20 to 30 mg once daily) is usually preferred to
propylthiouracil (PTU), except during pregnancy, because of its longer duration of action (allowing for
single daily dosing) and a lesser degree of toxicity.
● PTU (100 to 150 mg every six to eight hours) is preferred by some clinicians for the initial treatment of
thyroid storm since it reduces T4-to-T3 conversion.
● Patients who cannot take oral medications postoperatively will need rectal administration of thionamides,
which should be ordered well in advance from the pharmacy (table 2).
The clinical use of thionamides, including dosing, monitoring, and adverse effects is reviewed separately. (See
"Thionamides in the treatment of Graves' disease" and "Pharmacology and toxicity of thionamides" and
"Thyroid storm", section on 'Thionamides'.)
Iodine — If hyperthyroidism is severe and the need for surgery is urgent, we also add potassium
iodide solution (SSKI, one to five drops three times daily) one hour after thionamides.
Extreme caution is necessary before administering SSKI to a patient with known or suspected toxic
adenoma/MNG since iodine, in the absence of a thionamide to block organification, may exacerbate the
hyperthyroidism. Thionamide therapy should therefore be started first and continued without interruption,
preferably in divided dosing. If the patient is unable to continue oral thionamides and has been loaded with
iodine, hyperthyroidism may worsen. Thus, SSKI should not be used at all in a patient with toxic adenoma/MNG
if the patient will be unable to continue oral or rectal thionamides. In patients with Graves' disease, however,
exogenous iodine is unlikely to exacerbate hyperthyroidism by acting as substrate and therefore can be used in
combination with thionamides and beta blockers, or, in patients with thionamide intolerance, with beta blockers
alone. (See 'Intolerance to thionamides' below.)
Iodine blocks release of T4 and T3 from the gland and thereby shortens the time to achieving a euthyroid state.
This effect, however, may be transient, and the use of iodine to block release of hormone beyond 10 days is not
generally recommended; it can be started 10 days preoperatively for urgent procedures that are scheduled
more than 10 days in the future but which cannot be delayed until the patient is chemically euthyroid following a
thionamide.
Iopanoic acid (which is also rich in iodine) blocks both release of T4 and T3 from the gland and T4-to-T3
conversion but is not currently available in much of the world. Where available, iopanoic acid 500 mg daily
added to a thionamide will reduce thyroid hormone levels more rapidly than other regimens. If iopanoic acid is
available, the benefit of PTU over methimazole is moot (iopanoic acid is a more potent inhibitor of T4-to-T3
conversion), and methimazole should be used because of its longer duration of action. (See "Iodine in the
treatment of hyperthyroidism" and "Iodinated radiocontrast agents in the treatment of hyperthyroidism".)
Intolerance to thionamides — Adverse effects of thionamides include common, minor side effects
(eg, rash) and rare but serious adverse effects, such as agranulocytosis and hepatotoxicity. Although
thionamide toxicity is uncommon, some patients are unable to continue thionamides because of side effects or
because of allergy. (See "Pharmacology and toxicity of thionamides", section on 'Toxicities and their
management'.)
● Toxic adenoma/MNG – Patients with toxic adenoma/MNG who are intolerant or unable to take
thionamides should be pretreated with beta blockers alone.
● Graves' disease – Patients with Graves' hyperthyroidism who are allergic to or are intolerant of
thionamides can be treated with the combination of beta blockers and iodine.
● Severe hyperthyroidism – Patients with severe hyperthyroidism who are allergic to or unable to tolerate
thionamides can treated with beta blockers, glucocorticoids (to inhibit conversion of T4 to T3), bile acid
sequestrants (to reduce enterohepatic circulation of thyroid hormone), and, in patients with Graves'
disease, iodine. (See "Thyroid storm", section on 'Patients unable to take a thionamide'.)
Rarely, urgent thyroidectomy may be required prior to nonthyroidal surgery. (See "Surgical management of
hyperthyroidism", section on 'Preoperative preparation'.)
Thyroid storm — Patients with hyperthyroidism who are undergoing surgery are at risk for developing
thyroid storm, a condition that usually occurs during surgery or in the first 18 hours after the procedure. The
mortality rate for patients with thyroid storm can be as high as 40 percent (table 3). The clinical manifestations,
diagnosis, and treatment of thyroid storm are discussed in more detail separately. (See "Thyroid storm".)
SUMMARY AND RECOMMENDATIONS
● Despite the relatively high prevalence of thyroid disease in the general population, we believe there is no
need to screen for thyroid disease during the preoperative medical consultation. However, if the history and
physical examination are suggestive of thyroid disease, it is reasonable to try to make the diagnosis since
it can have effects upon perioperative management. (See 'Is preoperative measurement of TSH
necessary?' above and "Preoperative medical evaluation of the adult healthy patient".)
● For patients with subclinical hypothyroidism (elevated serum thyroid-stimulating hormone [TSH], normal
free thyroxine [T4]), we suggest not postponing surgery (Grade 2C). Such patients can proceed with either
urgent or elective surgeries. (See 'Subclinical hypothyroidism' above.)
● For patients with moderate (overt) hypothyroidism who require urgent surgery, we suggest not postponing
surgery (Grade 2C), with the knowledge that minor perioperative complications might develop. Such
patients should be treated with thyroid hormone as soon as the diagnosis is made. Generally, young
patients are started on close to full replacement doses of T4 (1.6 mcg/kg), while older patients or patients
with cardiopulmonary disease are started on 25 to 50 mcg daily with an increase in dose every two to six
weeks. (See 'Moderate (overt) hypothyroidism' above.)
On the other hand, when moderate hypothyroidism is discovered in a patient being evaluated for elective
surgery, we suggest postponing surgery until the euthyroid state is restored (Grade 2C). (See
'Management' above.)
● In patients with severe hypothyroidism (myxedema coma; severe clinical symptoms of chronic
hypothyroidism such as altered mentation, pericardial effusion, or heart failure; or very low levels of total
T4 [eg, less than 1.0 mcg/dL] or free T4 [eg, less than 0.5 ng/dL]), surgery should be delayed until
hypothyroidism has been treated. If emergency surgery is required, the severely hypothyroid patient should
be treated as soon as the diagnosis is made. If emergency surgery must be performed in a patient with
myxedema coma, we suggest treatment with both triiodothyronine (T3) and T4, rather than T4 alone
(Grade 2C). (See 'Severe hypothyroidism' above and "Myxedema coma", section on 'Treatment'.)
● Patients with autoimmune-mediated primary hypothyroidism may have concomitant primary adrenal
insufficiency. In addition, patients with central hypothyroidism may have associated hypopituitarism and
secondary adrenal insufficiency. If the status of the pituitary adrenal axis is uncertain and deficiency is
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considered likely in a patient with severe hypothyroidism requiring emergency surgery, patients should be
given stress doses of steroid until the integrity of the axis is ascertained. If the clinical situation permits, a
cosyntropin stimulation test should be performed prior to administering steroids. (See 'Severe
hypothyroidism' above and "Myxedema coma", section on 'Treatment'.)
● If the diagnosis of hypothyroidism is in doubt in a critically ill patient (because of the difficulty assessing
thyroid function in this population) and surgery cannot be postponed, we treat with thyroid hormone
replacement in the pre- and perioperative periods if there is clinical evidence to suggest a diagnosis of
moderate to severe hypothyroidism (eg, bradycardia and hypothermia along with slow mentation, puffy
face, a possible personal or strong family history of thyroid disease, or personal history of hypothalamic or
pituitary disease or cranial irradiation). In the absence of suspected myxedema coma, repletion should be
cautious, beginning with approximately half the expected full replacement dose of T4 (0.8 mcg/kg for
young patients and 25 to 50 mcg daily for older patients or patients with cardiopulmonary disease). (See
'Hospitalized/seriously ill patients with suspected hypothyroidism' above.)
● In our experience, patients with subclinical hyperthyroidism (low TSH, normal free T4 and T3) can typically
proceed with elective or urgent surgeries. Unless contraindicated, we administer a beta blocker
preoperatively to older patients (>50 years), or younger patients with cardiovascular disease, and taper
after recovery. (See 'Subclinical hyperthyroidism' above.)
● In patients with untreated or poorly controlled, overt hyperthyroidism, an acute event such as surgery can
precipitate thyroid storm, a potentially life-threatening condition. Thus, we suggest postponing surgery in
patients with newly discovered, overt hyperthyroidism until the patient has achieved adequate control of
their thyroid condition (usually three to eight weeks) (Grade 2C). (See 'Management' above and "Graves'
hyperthyroidism in nonpregnant adults: Overview of treatment" and "Treatment of toxic adenoma and toxic
multinodular goiter".)
For overtly hyperthyroid patients in whom surgery cannot be postponed, preoperative treatment of
hyperthyroidism should be initiated as soon as possible. (See 'Preoperative preparation for urgent surgery'
above.)
In the absence of contraindications, we recommend administering a beta blocker (Grade 1B), typically
atenolol 25 to 50 mg daily with the dose increased as needed to maintain the pulse rate below 80
beats/minute. Beta blockers should be continued until the patient's thyroid disease is under control.
Intravenous (IV) propranolol (0.5 to 1 mg over 10 minutes followed by 1 to 2 mg over 10 minutes every few
hours) can be used to control fever, hypertension, and tachycardia intraoperatively. (See 'Beta blockers'
above.)
In addition, once the diagnosis of hyperthyroidism due to Graves' disease or toxic adenoma/multinodular
goiter (MNG) is established, we suggest starting a thionamide (Grade 2B), with the aim of controlling
hyperthyroidism in the postoperative period. Methimazole (10 mg two to three times daily or 20 to 30 mg
once daily) is usually preferred to propylthiouracil (PTU), except during the first trimester of pregnancy,
because of its longer duration of action (allowing for single daily dosing) and a lesser degree of toxicity.
(See 'Thionamides' above.)
If hyperthyroidism is severe and the need for surgery is urgent, we suggest adding potassium iodide
solution (Grade 2B) (SSKI, one to five drops three times daily) one hour after thionamides. Iodide must
always be used cautiously. Iodide will not exacerbate hyperthyroidism due to Graves' disease in iodine-
replete areas, but iodide may worsen hyperthyroidism in patients with toxic adenoma or toxic MNG if
thionamides are not given continuously and, preferably, in divided doses. For patients who are unable to
continue oral thionamides, thionamides can be prepared for rectal administration (table 2). (See 'Iodine'
above.)
● For patients with Graves' hyperthyroidism who are allergic to or are intolerant of thionamides, the
combination of beta blockers and iodine can be used for preoperative preparation; corticosteroids and
cholestyramine can be added if the hyperthyroidism is severe. Patients with toxic adenoma/MNG who are
allergic to or are intolerant of thionamides should be treated with beta blockers alone, as iodine may
worsen hyperthyroidism. (See 'Intolerance to thionamides' above.)
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REFERENCES
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Topic 7858 Version 11.0

Nonthyroid Surgery in The Patient With Thyroid Disease - UpToDate

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Nonthyroid Surgery in The Patient With Thyroid Disease - UpToDate

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Nonthyroid surgery in the patient with thyroid disease - UpToDate 8/11/17 20(21

Authors: Ellen F Manzullo, MD, FACP, Douglas S Ross, MD

IS PREOPERATIVE MEASUREMENT OF TSH NECESSARY? — Despite the relatively high prevalence of

● Decreased gut motility results in constipation and ileus.

● A variety of metabolic abnormalities can occur in hypothyroidism, including hyponatremia due to a

● Mild hypothyroidism – Includes patients with subclinical hypothyroidism, defined biochemically as a

Subclinical hypothyroidism — We suggest not postponing surgery in patients with subclinical

The treatment of subclinical hypothyroidism is reviewed separately. (See "Subclinical hypothyroidism in

- T3 is given simultaneously in a dose of 5 to 20 mcg IV followed by 2.5 to 10 mcg every eight

HOSPITALIZED/SERIOUSLY ILL PATIENTS WITH SUSPECTED HYPOTHYROIDISM — Assessment of

● The serum TSH concentration may also be low.

● Subclinical hyperthyroidism is defined as a low TSH with normal free T4 and T3

Beta blockers — In the absence of contraindications, we administer a beta blocker preoperatively to

Thionamides — If hyperthyroidism is associated with an elevated radioiodine uptake (eg, toxic

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

1. Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism. Endocrinol Metab

INTRAVENOUS THYROXINE. Arch Intern Med 1964; 113:89.

Topic 7858 Version 11.0

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