Perioperative Management of Hypothyroid Patients Undergoing Nonthyroidal Surgery
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In these annotated PowerPoint slides I describe the perioperative evaluation and management of patients with hypothyroidism needing nonthyroid surgery. Remember to download these slides to view the annotations for each slide.
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Perioperative Management of Hypothyroid Patients Undergoing Nonthyroidal Surgery
- 1. Perioperative Management of the Hypothyroid Patient Undergoing Non-thyroid Surgery Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine The information contained in these slides is for educational purposes only and not meant to guide clinical care. Please refer to package inserts and guidelines for prescribing information.
- 2. Thyroid function is difficult to assess in seriously ill or hospitalized patients From UpToDate
- 3. Should preoperative TSH be measured? • No • Patients with known hypothyroidism on stable dose of medication • Checked in past 3-6 months • Yes • H&P suggesting of thyroid disease in undiagnosed patient • Poorly controlled symptoms in patients with known hypothyroidism
- 4. Hypothyroid effects that could influence perioperative outcomes • Cardiopulmonary • Decreased cardiac output • Hypoventilation • Reduced gut motility • Hyponatremia • Reduced drug clearance • Reduced clearance of Vit K dependent clotting factors • Observational outcomes studies • No differences in outcomes between euthyroid and moderately hypothyroid pts (Arch Intern Med 1983;143:893) • Hypothyroid pts with more hypo-tension, post op GI and neuropsych complications, & less likely to have fever with infection (Am J Med 1984;77:261) • Surgery can precipitate myxedema coma
- 5. Management of recently diagnosed patients with hypothyroidism Severity Elective Surgery Urgent/emergent Surgery Subclinical Proceed with surgery Proceed with surgery (Normal T4, elevated TSH) Mild-to-Moderate (Pts with overt hypothyroidism not meeting severe criteria) Postpone until euthyroid Initiate po THRT* • T4 (1.6 mcg/kg in young pts / 25-50 mcg daily in older pts or those with cardiac disease)† Severe (myxedema coma, severe clinical symptoms, or very low T4) Postpone until euthyroid Consult endocrinology IV thyroid hormone • T4 (200-300 mcg load, 50mcg daily) • T3 (5-20 mcg followed by 2.5-10 mcg Q8 hrs) Stress dose steroids * THRT= thyroid hormone replacement therapy † If only suspected hypothyroidism start lower dose (0.8 mcg/kg in younger pts)
- 6. Management of patients receiving chronic T4 therapy • Levothyroxine has a long half life (6-7 days) • Resume usual home dose when tolerating po • If oral intake cannot be resumed in 5-7 days give IV T4 at 70-80% of usual oral dose
Hinweis der Redaktion
- These PowerPoints will review management of the patient with hypothyroidism undergoing non-thyroid surgery.
- It can be difficult to assess thyroid function in patients who are seriously ill or hospitalized. Many have reductions in T4, T3, and TSH with elevations in reverse T3. This results from a transient central hypothyroidism. This also affects many patients undergoing surgery.
- Most patients with hypothyroidism will have well controlled symptoms and be on a stable dose of levothyroxine. These patients do not need preoperative assessment of thyroid function. Preoperative thyroid testing should be done in patients with symptoms suggestive of hypothyroidism, whether previously diagnosed with hypothyroidism or not. If surgery is emergent the results of testing are not likely to influence management.
- On the left portion of this slide are possible physiological effects that hypothyroidism could have during the perioperative period. Studies have shown mixed results of these effects on outcomes of surgery (right portion of slide). There are no randomized studies but only observational data that is quite dated. One study published in the Archives of Internal Medicine (Now JAMA Internal Medicine) found no differences in surgical outcomes (duration of anesthesia, BP, temp, fluid/electrolyte imbalances, arrhythmias, MI, sepsis, resp failure, time to discharge) between 59 hypothyroid and 59 paired euthyroid patients. Another study published in the American Journal of Medicine found that hypothyroid patients had higher rates of some complications (hypotension, heart failure, GI and neuropsych complications, less fever with infection) but there were no differences in duration of hospitalization, arrhythmia, hypothermia, hyponatremia, impaired wound healing, or death. Finally, it is important to realize that surgery can precipitate myedema coma in a severely hypothyroid patients. This is rare.
- There are no clinical trial data to guide optimal therapy. It is prudent to involve an endocrinologist in the management of many of these patients. This table outlines a suggested treatment strategy for hypothyroid patients undergoing nonthyroidal surgery. It is important to note that in patients with severe hypothyroidism there can be concomitant adrenal insufficiency. If the status of the pituitary axis is not known stress dose steroids should be given in addition to thyroid hormone. If time permits, a cosyntropin stimulation test should be done prior to administering steroids. I have another set of slides outlining steroid dosing in the perioperative period.
- Oral levothyroxine has a long half life (about a week). As long as patients resume eating in this time period no IV therapy is needed and the home dose can be resumed once tolerating po. If prolonged po is required then start IV T4 but at a reduced dose (70-80% of usual oral dose).