Nonthyroid Surgery in The Patient With Thyroid Disease

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Nonthyroid surgery in the patient with thyroid disease

AUTHORS: Ellen F Manzullo, MD, FACP, Douglas S Ross, MD
SECTION EDITOR: David S Cooper, MD
DEPUTY EDITOR: Jean E Mulder, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Feb 20, 2023.
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 healthy adult 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".)
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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' and "Thionamides in the treatment of Graves' disease", section on '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'.)
● 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].
However, a Chinese study of 548 patients with subclinical hypothyroidism compared with
euthyroid controls found slight, statistically significant increases in impaired wound
healing (3.7 versus 1.1 percent) and duration of inotropic support (4 versus 3 days)
following coronary bypass surgery [6].
Another Chinese study of 123 patients with subclinical hypothyroidism and TSH >10 mIU/L
found an increased incidence of postoperative infection following knee arthroplasty [7].
● Moderate overt hypothyroidism – Several studies have investigated the safety of general
anesthesia and surgery in patients with untreated or inadequately treated hypothyroidism
[2,8-13]. Surprisingly few adverse effects were reported, although the hypothyroid patients
had a higher frequency of peri- and postoperative ileus, hypotension, hyponatremia,
impaired wound healing, prolonged mechanical ventilation or reintubation, prolonged
inotropic support, 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.
• Another study investigated perioperative complications in 40 patients with mild to

moderate hypothyroidism compared with 80 matched controls [8]. 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.
• 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 [9,13].
• In a Chinese study, 189 patients with known hypothyroidism and thyroid function tests
consistent with overt hypothyroidism within two weeks of coronary artery surgery were
compared with euthyroid controls [6]. Hypothyroidism was associated with impaired
wound healing (11.8 versus 0.9 percent), increased mechanical ventilation (17 versus 15
hours) and reintubation (2.1 versus 0.4 percent), longer inotropic support (4 versus 3
days), and longer postoperative stay (4 versus 3 days).
● 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 [14,15]. In some case reports, myxedema coma is described as a rare
postoperative complication in patients with unrecognized severe hypothyroidism [16-19].
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 degree of thyroid test abnormality that warrants treatment with levothyroxine is
controversial. Selecting individuals for 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 [2,8]. (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 followed by 50 mcg daily.
• T3 is given simultaneously in a dose of 5 to 20 mcg intravenously 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 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 "Diagnosis of
adrenal insufficiency in adults", section on 'ACTH stimulation tests' and "Determining
the etiology of adrenal insufficiency in adults", section on 'Establish the level of defect'.)
• 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 [9,13]. (See 'Surgical outcomes' above.)
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. 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
intravenously 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'.)
SUSPECTED HYPOTHYROIDISM IN HOSPITALIZED/SERIOUSLY ILL PATIENTS
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 [20]. 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 [21]. 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 [22].
● 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 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 — Our recommendations for the management of nonthyroid surgery in

hyperthyroid patients are based on studies of patients undergoing thyroidectomy, who are
likely at higher risk for complications due to perioperative manipulation of the thyroid gland.
We also 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
There are insufficient data to evaluate the risks of nonthyroid surgery in hyperthyroid patients,
especially the risk of thyroid storm. A systemic literature review found 26 studies of patients
having surgery while hyperthyroid, but only one study included patients undergoing nonthyroid
surgery [23].
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" and "Subclinical
hyperthyroidism in nonpregnant adults", section on 'Management'.)
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 (normal free T4 and T3), which usually takes 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 [24]. 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, 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 [25]. Iodine will safely lower
thyroid hormone concentrations in Graves' disease, but it should be used cautiously and only
when hyperthyroidism is severe in patients with toxic adenoma/multinodular goiter since iodine
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can exacerbate hyperthyroidism in those patients unless iodine organification has been fully
blocked by pretreatment with a thionamide.
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 [26].
● 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 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 [27,28].
● 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 [29,30]. 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 [31-33]. 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 [31]. 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 [34]. (See "Beta blockers in the treatment of hyperthyroidism".)
Thionamides — If hyperthyroidism is due to Graves' disease, toxic adenoma, or

multinodular goiter, 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 is usually preferred to propylthiouracil, 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. Dosing depends on the degree of hyperthyroidism (biochemical
and clinical) and goiter size. (See "Thionamides in the treatment of Graves' disease",
section on 'Initiation of therapy'.)
● Propylthiouracil (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. (See "Thyroid
storm", section on 'Thionamides'.)
● 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 "Thionamides: Side
effects and toxicities".)
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/multinodular goiter 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/multinodular
goiter 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 propylthiouracil 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 "Thionamides: Side
effects and toxicities".)
● Toxic adenoma/multinodular goiter – Patients with toxic adenoma/multinodular goiter

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 'Thionamides'.)
Rarely, urgent thyroidectomy may be required prior to nonthyroidal surgery. (See "Surgical
management of hyperthyroidism", section on 'Preoperative preparation'.)
Preexisting hyperthyroidism — Patients who are taking a thionamide preoperatively

(whether chronic or recently started), who will not be able to take oral medications for longer
than a day or two postoperatively, can be treated with rectal preparations. Most hospital
pharmacies should be able to crush methimazole tablets and make a rectal suppository
( table 2); if possible, the pharmacy should be given advanced notice. However, for patients
well controlled on long-term methimazole therapy (TSH is normal), there is usually a delay of at
least 7 to 10 days before patients develop recurrent hyperthyroidism after omission of
treatment. In patients who have been on long-term treatment for more than 6 to 12 months,
recurrence after stopping treatment may take weeks or months, especially if thyroid-
stimulating immunoglobulins is no longer elevated. The decision to use rectal methimazole
postoperatively, therefore, depends on the patient's clinical status and the availability of rectal
preparations.
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). In a systemic review, the risk varied from 0 to 14 percent after
thyroidectomy [23]. The clinical manifestations, diagnosis, and treatment of thyroid storm are
discussed in more detail separately. (See "Thyroid storm".)
SUMMARY AND RECOMMENDATIONS
● Preoperative measurement of thyroid-stimulating hormone (TSH) – 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 healthy adult patient".)
● Approach to the patient with hypothyroidism undergoing nonthyroid surgery
• Subclinical hypothyroidism – For patients with subclinical hypothyroidism (elevated

serum 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.)
• Moderate hypothyroidism – 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.)
• Severe hypothyroidism – 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 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'.)
● Approach to the hospitalized or critically ill patient with suspected hypothyroidism –

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 'Suspected hypothyroidism in hospitalized/seriously ill

patients' above.)
● Approach to the patient with hyperthyroidism undergoing nonthyroid surgery
• Subclinical hyperthyroidism – 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.)
• Overt hyperthyroidism
- Elective surgery – 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 (normal free T4 and T3), which
usually takes three to eight weeks (Grade 2C). (See 'Overt hyperthyroidism' above
and "Graves' hyperthyroidism in nonpregnant adults: Overview of treatment" and
"Treatment of toxic adenoma and toxic multinodular goiter".)
- Urgent surgery – For overtly hyperthyroid patients in whom surgery cannot be

postponed, preoperative treatment of hyperthyroidism should be initiated as soon
as possible. (See 'Overt hyperthyroidism' above and 'Preoperative preparation for
urgent surgery' above.)
● Preoperative preparation for urgent surgery
• Beta blockers – 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 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.)
• Thionamides – In addition, once the diagnosis of hyperthyroidism due to Graves'

disease or toxic adenoma/multinodular goiter 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, 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.)
• Potassium iodide for severe hyperthyroidism – 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 multinodular goiter 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.)
• Intolerance to thionamides – 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/multinodular goiter 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.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism.

Endocrinol Metab Clin North Am 2003; 32:503.
2. Weinberg AD, Brennan MD, Gorman CA, et al. Outcome of anesthesia and surgery in
hypothyroid patients. Arch Intern Med 1983; 143:893.
3. Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone
reduction on perioperative outcome. Anesth Analg 1997; 85:30.
4. Park YJ, Yoon JW, Kim KI, et al. Subclinical hypothyroidism might increase the risk of
transient atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2009;
87:1846.
5. Sherman SI, Ladenson PW. Percutaneous transluminal coronary angioplasty in

hypothyroidism. Am J Med 1991; 90:367.
6. Zhao D, Xu F, Yuan X, Feng W. Impact of subclinical hypothyroidism on outcomes of
coronary bypass surgery. J Card Surg 2021; 36:1431.
7. Jing W, Long G, Yan Z, et al. Subclinical Hypothyroidism Affects Postoperative Outcome of
Patients Undergoing Total Knee Arthroplasty. Orthop Surg 2021; 13:932.
8. Ladenson PW, Levin AA, Ridgway EC, Daniels GH. Complications of surgery in hypothyroid
patients. Am J Med 1984; 77:261.
9. Drucker DJ, Burrow GN. Cardiovascular surgery in the hypothyroid patient. Arch Intern Med
1985; 145:1585.
10. Zhao D, Feng W, Zhao W, et al. Impact of Overt Hypothyroidism on Early Outcomes of
Coronary Artery Surgery. Heart Surg Forum 2021; 24:E870.
11. Bajaj A, Shah RM, Kurapaty S, et al. Hypothyroidism and Spine Surgery: a Review of Current
Findings. Curr Rev Musculoskelet Med 2023; 16:33.
12. Yang S, Zhao H, Yang J, et al. Risk factors of early postoperative bowel obstruction for
patients undergoing selective colorectal surgeries. BMC Gastroenterol 2021; 21:480.
13. Myerowitz PD, Kamienski RW, Swanson DK, et al. Diagnosis and management of the
hypothyroid patient with chest pain. J Thorac Cardiovasc Surg 1983; 86:57.
14. Abbott TR. Anaesthesia in untreated myxoedema. Report of two cases. Br J Anaesth 1967;
39:510.
15. Kim JM, Hackman L. Anesthesia for untreated hypothyroidism: report of three cases.
Anesth Analg 1977; 56:299.
16. Appoo JJ, Morin JF. Severe cerebral and cardiac dysfunction associated with thyroid
decompensation after cardiac operations. J Thorac Cardiovasc Surg 1997; 114:496.
17. CATZ B, RUSSELL S. Myxedema, shock and coma. Seven survival cases. Arch Intern Med
1961; 108:407.
18. HOLVEY DN, GOODNER CJ, NICOLOFF JT, DOWLING JT. TREATMENT OF MYXEDEMA COMA
WITH INTRAVENOUS THYROXINE. Arch Intern Med 1964; 113:89.
19. Ragaller M, Quintel M, Bender HJ, Albrecht DM. [Myxedema coma as a rare postoperative
complication]. Anaesthesist 1993; 42:179.
20. Fliers E, Bianco AC, Langouche L, Boelen A. Thyroid function in critically ill patients. Lancet
Diabetes Endocrinol 2015; 3:816.
21. Chopra IJ. Clinical review 86: Euthyroid sick syndrome: is it a misnomer? J Clin Endocrinol
Metab 1997; 82:329.
22. Frost L, Vestergaard P, Mosekilde L. Hyperthyroidism and risk of atrial fibrillation or flutter:
a population-based study. Arch Intern Med 2004; 164:1675.
23. de Mul N, Damstra J, Nieveen van Dijkum EJM, et al. Risk of perioperative thyroid storm in
hyperthyroid patients: a systematic review. Br J Anaesth 2021; 127:879.
24. Woeber KA. Thyrotoxicosis and the heart. N Engl J Med 1992; 327:94.
25. Langley RW, Burch HB. Perioperative management of the thyrotoxic patient. Endocrinol
Metab Clin North Am 2003; 32:519.
26. Geffner DL, Hershman JM. Beta-adrenergic blockade for the treatment of hyperthyroidism.
Am J Med 1992; 93:61.
27. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab
Clin North Am 1993; 22:263.
28. Das G, Krieger M. Treatment of thyrotoxic storm with intravenous administration of

propranolol. Ann Intern Med 1969; 70:985.
29. Fujita Y, Shimizu T, Matsumoto A, Aoki M. [Perioperative and postoperative management of
two patients with uncontrolled hyperthyroidism using short acting beta blocker, landiolol].
Masui 2008; 57:1143.
30. Mizunoya K, Maruyama T, Fujii T, et al. [Anesthetic and perioperative management of a
patient with uncontrolled thyrotoxicosis undergoing coronary artery bypass grafting
surgery]. Masui 2013; 62:1214.
31. Adlerberth A, Stenström G, Hasselgren PO. The selective beta 1-blocking agent metoprolol
compared with antithyroid drug and thyroxine as preoperative treatment of patients with
hyperthyroidism. Results from a prospective, randomized study. Ann Surg 1987; 205:182.
32. Vickers P, Garg KM, Arya R, et al. The role of selective beta 1-blocker in the preoperative
preparation of thyrotoxicosis: a comparative study with propranolol. Int Surg 1990; 75:179.
33. Feek CM, Sawers JS, Irvine WJ, et al. Combination of potassium iodide and propranolol in
preparation of patients with Graves' disease for thyroid surgery. N Engl J Med 1980;
302:883.
34. Eriksson M, Rubenfeld S, Garber AJ, Kohler PO. Propranolol does not prevent thyroid storm.
N Engl J Med 1977; 296:263.
Topic 7858 Version 17.0
GRAPHICS
Clinical features of myxedema coma
Decreased mental status
Hypothermia
Bradycardia
Hyponatremia
Hypoglycemia
Hypotension
Precipitating illness
Graphic 54836 Version 1.0
Thyroid function tests in nonthyroidal illness
Schematic representation of the changes in thyroid function tests in patients with nonthyroidal illness of
increasing severity.
rT3: reverse triiodothyronine; T4: thyroxine; TSH: thyroid-stimulating hormone; T3: triiodothyronine.
Preparation of rectal formulations of thionamides
Methimazole
Suppository Dissolve 1200 mg methimazole in 12 mL of water, and add to 52 mL cocoa butter

containing 2 drops of polysorbate (Span) 80. Stir mixture to form an emulsion, and
pour into 2.6 mL suppository molds to cool. [1]
Propylthiouracil
Suppository Dissolve 200 mg of propylthiouracil in a polyethylene glycol base, and put into
suppository tablets.
Retention Dissolve 8 to 12 (50 mg) tablets of propylthiouracil in 90 mL of sterile water.

enema
OR
Dissolve 8 (50 mg) tablets of propylthiouracil in 60 mL of mineral oil enema (eg, Fleet
mineral oil) or in 60 mL of sodium phosphates enema solution* (eg, Fleet enema
phospho-soda). [2]
For either enema preparation: Administer by Foley catheter inserted into the rectum,
with balloon inflated to prevent leakage for 2-hour retention.
Additional information on preparation described in:

Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006;
35:663.
Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the
treatment of thyroid storm. Thyroid 1995; 5:403.
Jongjaroenprasert W, Akarawut W, Chantasart D, et al. Rectal administration of propylthiouracil in
hyperthyroid patients: comparison of suspension enema and suppository form. Thyroid 2002;
12:627.
* Avoid phosphate-containing rectal preparations in patients with kidney insufficiency or heart failure.
References:
1. Nabil N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab 1982; 54:180.
2. Walter RM Jr, Bartle WR. Rectal administration of propylthiouracil in the treatment of Graves' disease. Am J Med 1990;
88:69.
Diagnostic criteria for thyroid storm*
Thermoregulatory dysfunction Cardiovascular dysfunction
Temperature (°F | °C) Tachycardia
99 to 99.9 | 37.2 to 37.7 5 99 to 109 5
100 to 100.9 | 37.8 to 38.2 10 110 to 119 10
101 to 101.9 | 38.3 to 38.8 15 120 to 129 15
102 to 102.9 | 38.9 to 39.4 20 130 to 139 20
103 to 103.9 | 39.4 to 39.9 25 ≥140 25
≥104.0 | >40.0 30 Atrial fibrillation 10
Central nervous system effects Heart failure

Mild 10 Mild 5
Agitation Pedal edema
Moderate 20 Moderate 10
Delirium Bibasilar rales
Psychosis Severe 15
Extreme lethargy Pulmonary edema
Severe 30 Precipitant history

Seizure Negative 0
Coma Positive 10
Gastrointestinal-hepatic dysfunction
Moderate 10
Diarrhea
Nausea/vomiting
Abdominal pain
Severe 20
Unexplained jaundice
* A score of 45 or more is highly suggestive of thyroid storm, a score of 25 to 44 supports the diagnosis,
and a score below 25 makes thyroid storm unlikely.
Adapted from: Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;
22:263.
Contributor Disclosures
Ellen F Manzullo, MD, FACP No relevant financial relationship(s) with ineligible companies to
disclose. Douglas S Ross, MD Consultant/Advisory Boards: Medullary Thyroid Cancer Registry Consortium
[Thyroid cancer]. All of the relevant financial relationships listed have been mitigated. David S Cooper,
MD No relevant financial relationship(s) with ineligible companies to disclose. Jean E Mulder, MD No
relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Literature review current through: Jan 2024.

IS PREOPERATIVE MEASUREMENT OF TSH NECESSARY?

Clinical manifestations that may impact perioperative outcome — Hypothyroidism affects

● The systemic hypometabolism that is associated with hypothyroidism results in a decrease

● Hypoventilation occurs because of respiratory muscle weakness and reduced pulmonary

● Decreased gut motility results in constipation and ileus.

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

● Moderate hypothyroidism – Includes all other patients with overt hypothyroidism

● Mild hypothyroidism – Includes patients with subclinical hypothyroidism, defined

Surgical outcomes — Observational studies evaluating surgical outcomes in patients with

● Mild (subclinical) hypothyroidism – There are few data on surgical outcomes in

• One study investigated anesthetic and surgical outcomes in 59 hypothyroid patients

• Another study investigated perioperative complications in 40 patients with mild to

• Retrospective and prospective studies of cardiac patients found no adverse outcomes

● Severe hypothyroidism – Older case studies in the anesthesia literature reported

sedatives, and anesthesia in undiagnosed patients with more severe hypothyroidism,

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

Moderate (overt) hypothyroidism — Our approach in patients with moderate

When a diagnosis of moderate hypothyroidism is made preoperatively, thyroid hormone

● Urgent surgery – If emergency surgery must be performed in a patient with severe

• T3 is given simultaneously in a dose of 5 to 20 mcg intravenously followed by 2.5 to 10

Use of an arterial line and Swan-Ganz catheter should be considered if cardiopulmonary

• Consider adrenal insufficiency – Rarely, Addison disease will be present in a patient

• Postoperative concerns – In the postoperative period, the patient's fluid and

Cardiovascular surgery — Patients with hypothyroidism who are scheduled to undergo

Preexisting hypothyroidism — Patients with a history of hypothyroidism receiving chronic T4

SUSPECTED HYPOTHYROIDISM IN HOSPITALIZED/SERIOUSLY ILL PATIENTS

● The majority of hospitalized patients have a low serum T3 concentration. Abnormalities in

● From 15 to 20 percent of hospitalized patients and up to 50 percent of patients in intensive

● The serum TSH concentration may also be low.

● Distinguishing nonthyroidal illness from primary hypothyroidism – In most critically ill

● Distinguishing nonthyroidal illness and central hypothyroidism – Patients with severe

• Elective surgery – In this setting, nonurgent surgeries should be postponed, and

• Urgent surgery – If the diagnosis of hypothyroidism is in doubt in a critically ill patient

In the absence of suspected myxedema coma, repletion should be cautious, beginning

Clinical manifestations that may impact perioperative outcome — As with hypothyroidism,

● Atrial fibrillation occurs in approximately 8 percent of patients with hyperthyroidism and is

Management — Our recommendations for the management of nonthyroid surgery in

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

Subclinical hyperthyroidism — In our experience, patients with subclinical hyperthyroidism

Overt hyperthyroidism — In patients with untreated or poorly controlled hyperthyroidism, an

● Urgent surgery – For overtly hyperthyroid patients in whom surgery cannot be

Preoperative preparation for urgent surgery — Preoperative preparation typically

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

● Intravenous propranolol (0.5 to 1 mg over 10 minutes followed by 1 to 2 mg over 10

Thionamides — If hyperthyroidism is due to Graves' disease, toxic adenoma, or

● Methimazole is usually preferred to propylthiouracil, except during the first trimester of

Intolerance to thionamides — Adverse effects of thionamides include common, minor

● Toxic adenoma/multinodular goiter – Patients with toxic adenoma/multinodular goiter

● Severe hyperthyroidism – Patients with severe hyperthyroidism who are allergic to or

Preexisting hyperthyroidism — Patients who are taking a thionamide preoperatively

SUMMARY AND RECOMMENDATIONS

● Preoperative measurement of thyroid-stimulating hormone (TSH) – Despite the

● Approach to the patient with hypothyroidism undergoing nonthyroid surgery

• Subclinical hypothyroidism – For patients with subclinical hypothyroidism (elevated

• Moderate hypothyroidism – For patients with moderate (overt) hypothyroidism who

On the other hand, when moderate hypothyroidism is discovered in a patient being

• Severe hypothyroidism – In patients with severe hypothyroidism (myxedema coma;

Patients with autoimmune-mediated primary hypothyroidism may have concomitant

● Approach to the hospitalized or critically ill patient with suspected hypothyroidism –