This is a common case scenario for all of us
Elective surgery with abnormal Thyroid function test
We are trying to evolve acceptable guidelines that we can enforce on our surgeons but they need to be reasonable and scientifically backed too
Would like to place 3 scenarios and also give my take on it
SCENARIO 1
Hyperthyroid MNG coming for total thyroidectomy.
Treated for last 2 weeks with Carbamizole and Propronolol.
Last TFT
T3 -↑
T4 - ↑
TSH - ↓
Surgeon wants to proceed with surgery without waiting for biochemical correction
OUR TAKE
Treat for 3 – 6 weeks
Look for improvement in clinical signs like weight gain, less hunger and Sleeping pulse rate < 80bpm. Forget tremors
Forget absolute biochemical correction.
Look for 2 TFT showing trend towards improvement.
Accept at increased risk for adverse peri-operative cardiorespiratory event
SCENARIO 2
Hypothyroid coming for thyroidectomy
On thyroxine
Last TFT
T3 -↓
T4 - ↓
TSH - ↑
Surgeon wants to proceed with surgery without waiting for biochemical correction
OUR TAKE
Treat for 4 -6 weeks
Carefully evaluate for IHD
Forget absolute biochemical correction.
Look for 2 TFT showing trend towards improvement.
Accept at increased risk for adverse peri-operative cardiorespiratory event
SCENARIO 3
THE TOUGHEST
Hypo(more common) or Hyperthyroid coming for quasi emergency surgery like Upper humerus fixation or Lumbar disc disease with compression for laminectomy
Just detected
Treatment just started
No time to wait for 2 -3 weeks
OUR TAKE
Start on appropriate treatment atleast 3 to 7 days
Look for Free T3 and Free T4 index and hopefully if they are OK proceed with surgery even if the rest of the TFT is abnormal
WOULD APPRECIATE YOUR INPUT AND PRACTICE GUIDELINES IN THESE SCENARIOS
regs
CONSIDER SUPERF. & DEEP CERVICAL BLOCK + GA
The problem is GA- you still have to give it. There lies the problem
So how does the block actually help
Also
Would you do these blocks bilaterally for Total Thyroidectomy
regs
usually it is given bilaterally.
Dear Dr Sandi
One of the complications of deep cervical plexus block is Phrenic nerve palsy and hence unilateral paralysis of diaphragm.
This complication is also seen in interscalene approach to Brachial plexus
Hence for very obvious reasons bilateral cervical plexus block cannot be recommended as safe anaesthetic practice.
You might end up with a non-ventilating patient.
Similarly it is better to avoid CVC attempts on both sides at the same sitting.
Bilateral botched up attempts could mean a potential for bilateral pneumothorax and that again is deemed as unsafe anaesthetic practice.
regs
hi jafo sir,
in first 2 scenario i fully agree with you.giving bilaetral deep cervical/superficial plexus blocks can't be justified keeping in mind respiratory complications/sir, in third scenario as humerus fixation is an emergency surgery can we try interscalene block or something regional block in case of lumbar disc disease.waiting for ur suggestion.regards