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A 48-year-old man with thyrotoxicosis presented with diffuse neck enlargement
.
History of present illness: significant dyspnea, dysphagia, weight loss, paroxysmal palpitations and heat intolerance
.
Blood pressure 160/100 mmHg, heart rate 120 beats/min, hematocrit 29%
.
C.
Intraoperative Management 1.
How is this patient monitored intraoperatively? 2.
How is anesthesia induction performed? 3.
Is tracheal intubation necessary for this procedure? Discuss the type and length of catheter that should be used
.
4.
How should anesthesia be maintained? 5.
During the operation, the patient developed hyperthermia and tachycardia
.
Discuss the differential diagnosis of malignant hyperthermia and thyroid storm
.
How should it be handled? 6.
How to remove the patient's endotracheal tube? D.
Postoperative Management 1.
How should the differential diagnosis and treatment be done when the patient develops wheezing and dyspnea in the recovery room? 2.
When is thyroid storm likely to occur? Partial breakdown C.
Intraoperative management C1.
How was this patient monitored intraoperatively? Patients with thyrotoxicosis should have blood pressure, end-tidal carbon dioxide, pulse oximetry, electrocardiogram, and core temperature monitoring to manage any symptoms of cardiac decompensation and detect increased thyroid and adrenergic activity in time
.
If a patient is admitted to the operating room in a state of hyperthyroid crisis, multiple large venous access and one arterial access should be opened immediately
.
A central venous or pulmonary artery catheter is recommended if the patient has current or previous congestive heart failure, myocardial ischemia, renal failure, or hypotension
.
Invasive monitoring should be placed before skin incision
.
Once surgery has begun, repositioning monitoring can be difficult
.
C2.
How to perform anesthesia induction? If no airway obstruction is predicted, induction and intubation can be performed using standard methods
.
Patients with orthopnea, dyspnea, stridor, wheezing, or hoarseness require further preoperative evaluation
.
Carefully review the preoperative examination as described in question B3
.
The anesthesiologist should at least evaluate the chest X-ray before surgery
.
When the airway is obstructed, fiberoptic bronchoscopy-guided intubation must be performed in the awake state or inhalation anesthesia-induced intubation with preserved spontaneous breathing
.
Inhalation induction with halothane or sevoflurane preserves spontaneous breathing and airway patency
.
Isoflurane and desflurane are not suitable for inhalation induction due to their pungent odor
.
Intubation should only be attempted after a stage of deep anesthesia has been achieved
.
Patients with severe obstruction require awake intubation, requiring anesthesia of the glossopharyngeal nerve, superior laryngeal nerve, and recurrent laryngeal nerve
.
Intubation requires careful use of a small amount of sedative or anxiolytic to prevent thyroid storm
.
A rigid bronchoscope should be prepared to manage a collapsed airway
.
Emergency tracheotomy is difficult due to anatomical variation and abundant tissue blood vessels
.
A small reinforced endotracheal tube should be available
.
C3.
Is tracheal intubation necessary for this procedure? Discuss the type and length of catheter that should be used
.
Tracheal intubation is necessary for thyroid surgery
.
If airway obstruction is suspected, a reinforced endotracheal tube should be used to prevent airway collapse
.
The length of the catheter should be long enough to cross the thyroid gland
.
C4.
How should anesthesia be maintained? Anesthesia maintenance should avoid sympathetic nervous system excitation
.
Muscle relaxants are not necessary
.
Analgesics such as fentanyl or morphine need only be given in small amounts to ensure that the patient is awake and able to maintain airway after extubation
.
The use of sympathomimetic drugs to manage hypotension must account for possible overreaction
.
Because of the high levels of circulating endogenous catecholamines, direct-acting sympathomimetic drugs (such as epinephrine or norepinephrine), or alpha-receptor agonists (such as phenylephrine) are more effective than indirect-acting sympathomimetic drugs (such as ephedrine or metahydroxylamine) are more suitable for the management of intraoperative hypotension
.
C5.
During surgery, the patient presented with hyperthermia and tachycardia
.
Discuss the differential diagnosis of malignant hyperthermia and thyroid storm
.
How should it be handled? The differential diagnosis includes hyperthyroid crisis, malignant hyperthermia, pheochromocytoma, and carcinoid syndrome
.
Most of the clinical manifestations of malignant hyperthermia and hyperthyroid crisis are related to the body compensation caused by hyperthermia
.
However, malignant hyperthermia results in metabolic acidosis, severe hypercapnia, and muscle rigidity, which are not present in hyperthyroid crisis
.
The level of creatine phosphokinase decreased to half the normal value in patients with hyperthyroidism, while the level of creatine phosphokinase increased in patients with malignant hyperthermia
.
In both cases, prompt intervention must be implemented
.
Once a hyperthyroid crisis is suspected, treatment must be started immediately
.
The goals of treatment are as follows: • Diagnosis and treatment of the causative agent
.
• Supportive care
.
Replenish hydration, glucose and electrolytes
.
Use paracetamol, cold infusion of body cavity, cooling blanket, ice pack, and lowering of ambient temperature to reduce body temperature
.
Do not use aspirin as a fever reducer
.
It replaces the binding of thyroid hormone to protein, thereby increasing the level of free hormone
.
Once acute congestive heart failure occurs, inotropes, diuretics, and oxygen are required
.
• Reduced secretion and production of thyroid hormones
.
Antithyroid drugs block the binding of iodide within the thyroid within one hour of administration
.
One hour after methimazole or propylthiouracil is given, iodine therapy can be started
.
• Blocks the metabolic effects of thyroid hormones
.
Metabolism-related clinical symptoms can be treated with beta-blockers such as propranolol or catecholamine-depleting drugs such as reserpine
.
C6.
How to remove the patient's tracheal tube? If tracheomalacia is suspected, assessment of airway patency under direct vision is recommended
.
Fiberoptic bronchoscopy can be used to assess airway collapse and movement of the vocal cords by slowly retracting the tracheal tube and bronchoscope together
.
If the trachea is found to be collapsed, the endotracheal tube and bronchoscope should be reinserted immediately
.
The vocal cords must also be assessed
.
The endotracheal tube should not be removed if the patient's ability to protect the airway is questionable
.
A tracheostomy kit, tracheal tube, and laryngoscope should be available at the bedside
.
D.
Postoperative management D 1.
How to make differential diagnosis and treatment when a patient develops wheezing and dyspnea in the recovery room? Causes of respiratory failure include hemorrhage, airway obstruction, recurrent laryngeal nerve palsy, tracheomalacia, pneumothorax, and hypocalcemia
.
Signs of airway obstruction require urgent evaluation
.
Hematomas cause compressive airway obstruction and restrict venous and lymphatic return to the airway mucosa
.
Hematoma evacuation requires opening and drainage of the wound
.
However, airway obstruction due to mucosal edema may persist
.
Patients should be intubated as early as possible before airway edema due to restricted lymphatic and venous return occurs
.
Initially, the patient can be seated at a 45-degree angle to facilitate venous return
.
Nebulized corticosteroids and racemic epinephrine reduce swelling in the throat
.
If the dyspnea worsens, the patient should be reintubated
.
Bilateral recurrent laryngeal nerve injury can cause respiratory obstruction
.
The patient's true vocal cords were in paramedian position on both sides
.
Such patients require urgent airway management such as endotracheal intubation or tracheostomy
.
Hoarseness occurs in patients with unilateral recurrent laryngeal nerve injury, while airway obstruction is mild
.
If the incision goes down to the mediastinum, the possibility of a pneumothorax causing post-operative dyspnea needs to be ruled out
.
Hypocalcemia secondary to the removal of parathyroid tissue usually develops symptoms within 3 days of surgery
.
Acute airway obstruction that occurs immediately after surgery is uncommon
.
Patients usually have perioral numbness and tingling in the hands and feet
.
If calcium supplementation is not timely, patients will develop stridor and airway obstruction secondary to muscle weakness
.
Severe hypocalcemia can lead to seizures and tetany
.
D2.
When is thyroid storm likely to occur? Thyroid storm usually occurs 6-18 hours after surgery, not during surgery
.
Treatment measures are based on the same principles as emergency surgery (see B9).
o Supportive measures such as fluids, oxygen, and cooling are important
.
Aspirin is usually not used as a fever reducer
.
It can replace the binding of thyroid hormone to protein, which leads to an increase in free thyroid hormone levels
.
Luffy Medical Channel Notes - Fart Peach Typography - Flesh
.
History of present illness: significant dyspnea, dysphagia, weight loss, paroxysmal palpitations and heat intolerance
.
Blood pressure 160/100 mmHg, heart rate 120 beats/min, hematocrit 29%
.
C.
Intraoperative Management 1.
How is this patient monitored intraoperatively? 2.
How is anesthesia induction performed? 3.
Is tracheal intubation necessary for this procedure? Discuss the type and length of catheter that should be used
.
4.
How should anesthesia be maintained? 5.
During the operation, the patient developed hyperthermia and tachycardia
.
Discuss the differential diagnosis of malignant hyperthermia and thyroid storm
.
How should it be handled? 6.
How to remove the patient's endotracheal tube? D.
Postoperative Management 1.
How should the differential diagnosis and treatment be done when the patient develops wheezing and dyspnea in the recovery room? 2.
When is thyroid storm likely to occur? Partial breakdown C.
Intraoperative management C1.
How was this patient monitored intraoperatively? Patients with thyrotoxicosis should have blood pressure, end-tidal carbon dioxide, pulse oximetry, electrocardiogram, and core temperature monitoring to manage any symptoms of cardiac decompensation and detect increased thyroid and adrenergic activity in time
.
If a patient is admitted to the operating room in a state of hyperthyroid crisis, multiple large venous access and one arterial access should be opened immediately
.
A central venous or pulmonary artery catheter is recommended if the patient has current or previous congestive heart failure, myocardial ischemia, renal failure, or hypotension
.
Invasive monitoring should be placed before skin incision
.
Once surgery has begun, repositioning monitoring can be difficult
.
C2.
How to perform anesthesia induction? If no airway obstruction is predicted, induction and intubation can be performed using standard methods
.
Patients with orthopnea, dyspnea, stridor, wheezing, or hoarseness require further preoperative evaluation
.
Carefully review the preoperative examination as described in question B3
.
The anesthesiologist should at least evaluate the chest X-ray before surgery
.
When the airway is obstructed, fiberoptic bronchoscopy-guided intubation must be performed in the awake state or inhalation anesthesia-induced intubation with preserved spontaneous breathing
.
Inhalation induction with halothane or sevoflurane preserves spontaneous breathing and airway patency
.
Isoflurane and desflurane are not suitable for inhalation induction due to their pungent odor
.
Intubation should only be attempted after a stage of deep anesthesia has been achieved
.
Patients with severe obstruction require awake intubation, requiring anesthesia of the glossopharyngeal nerve, superior laryngeal nerve, and recurrent laryngeal nerve
.
Intubation requires careful use of a small amount of sedative or anxiolytic to prevent thyroid storm
.
A rigid bronchoscope should be prepared to manage a collapsed airway
.
Emergency tracheotomy is difficult due to anatomical variation and abundant tissue blood vessels
.
A small reinforced endotracheal tube should be available
.
C3.
Is tracheal intubation necessary for this procedure? Discuss the type and length of catheter that should be used
.
Tracheal intubation is necessary for thyroid surgery
.
If airway obstruction is suspected, a reinforced endotracheal tube should be used to prevent airway collapse
.
The length of the catheter should be long enough to cross the thyroid gland
.
C4.
How should anesthesia be maintained? Anesthesia maintenance should avoid sympathetic nervous system excitation
.
Muscle relaxants are not necessary
.
Analgesics such as fentanyl or morphine need only be given in small amounts to ensure that the patient is awake and able to maintain airway after extubation
.
The use of sympathomimetic drugs to manage hypotension must account for possible overreaction
.
Because of the high levels of circulating endogenous catecholamines, direct-acting sympathomimetic drugs (such as epinephrine or norepinephrine), or alpha-receptor agonists (such as phenylephrine) are more effective than indirect-acting sympathomimetic drugs (such as ephedrine or metahydroxylamine) are more suitable for the management of intraoperative hypotension
.
C5.
During surgery, the patient presented with hyperthermia and tachycardia
.
Discuss the differential diagnosis of malignant hyperthermia and thyroid storm
.
How should it be handled? The differential diagnosis includes hyperthyroid crisis, malignant hyperthermia, pheochromocytoma, and carcinoid syndrome
.
Most of the clinical manifestations of malignant hyperthermia and hyperthyroid crisis are related to the body compensation caused by hyperthermia
.
However, malignant hyperthermia results in metabolic acidosis, severe hypercapnia, and muscle rigidity, which are not present in hyperthyroid crisis
.
The level of creatine phosphokinase decreased to half the normal value in patients with hyperthyroidism, while the level of creatine phosphokinase increased in patients with malignant hyperthermia
.
In both cases, prompt intervention must be implemented
.
Once a hyperthyroid crisis is suspected, treatment must be started immediately
.
The goals of treatment are as follows: • Diagnosis and treatment of the causative agent
.
• Supportive care
.
Replenish hydration, glucose and electrolytes
.
Use paracetamol, cold infusion of body cavity, cooling blanket, ice pack, and lowering of ambient temperature to reduce body temperature
.
Do not use aspirin as a fever reducer
.
It replaces the binding of thyroid hormone to protein, thereby increasing the level of free hormone
.
Once acute congestive heart failure occurs, inotropes, diuretics, and oxygen are required
.
• Reduced secretion and production of thyroid hormones
.
Antithyroid drugs block the binding of iodide within the thyroid within one hour of administration
.
One hour after methimazole or propylthiouracil is given, iodine therapy can be started
.
• Blocks the metabolic effects of thyroid hormones
.
Metabolism-related clinical symptoms can be treated with beta-blockers such as propranolol or catecholamine-depleting drugs such as reserpine
.
C6.
How to remove the patient's tracheal tube? If tracheomalacia is suspected, assessment of airway patency under direct vision is recommended
.
Fiberoptic bronchoscopy can be used to assess airway collapse and movement of the vocal cords by slowly retracting the tracheal tube and bronchoscope together
.
If the trachea is found to be collapsed, the endotracheal tube and bronchoscope should be reinserted immediately
.
The vocal cords must also be assessed
.
The endotracheal tube should not be removed if the patient's ability to protect the airway is questionable
.
A tracheostomy kit, tracheal tube, and laryngoscope should be available at the bedside
.
D.
Postoperative management D 1.
How to make differential diagnosis and treatment when a patient develops wheezing and dyspnea in the recovery room? Causes of respiratory failure include hemorrhage, airway obstruction, recurrent laryngeal nerve palsy, tracheomalacia, pneumothorax, and hypocalcemia
.
Signs of airway obstruction require urgent evaluation
.
Hematomas cause compressive airway obstruction and restrict venous and lymphatic return to the airway mucosa
.
Hematoma evacuation requires opening and drainage of the wound
.
However, airway obstruction due to mucosal edema may persist
.
Patients should be intubated as early as possible before airway edema due to restricted lymphatic and venous return occurs
.
Initially, the patient can be seated at a 45-degree angle to facilitate venous return
.
Nebulized corticosteroids and racemic epinephrine reduce swelling in the throat
.
If the dyspnea worsens, the patient should be reintubated
.
Bilateral recurrent laryngeal nerve injury can cause respiratory obstruction
.
The patient's true vocal cords were in paramedian position on both sides
.
Such patients require urgent airway management such as endotracheal intubation or tracheostomy
.
Hoarseness occurs in patients with unilateral recurrent laryngeal nerve injury, while airway obstruction is mild
.
If the incision goes down to the mediastinum, the possibility of a pneumothorax causing post-operative dyspnea needs to be ruled out
.
Hypocalcemia secondary to the removal of parathyroid tissue usually develops symptoms within 3 days of surgery
.
Acute airway obstruction that occurs immediately after surgery is uncommon
.
Patients usually have perioral numbness and tingling in the hands and feet
.
If calcium supplementation is not timely, patients will develop stridor and airway obstruction secondary to muscle weakness
.
Severe hypocalcemia can lead to seizures and tetany
.
D2.
When is thyroid storm likely to occur? Thyroid storm usually occurs 6-18 hours after surgery, not during surgery
.
Treatment measures are based on the same principles as emergency surgery (see B9).
o Supportive measures such as fluids, oxygen, and cooling are important
.
Aspirin is usually not used as a fever reducer
.
It can replace the binding of thyroid hormone to protein, which leads to an increase in free thyroid hormone levels
.
Luffy Medical Channel Notes - Fart Peach Typography - Flesh
