Surgical removal of the thyroid has historically been a risky procedure due to limited understanding of the anatomy and functions of the gland, the potential for bleeding, and other complications. Minimally invasive procedures and more sophisticated intraoperative monitoring have now allowed for a thyroidectomy to be a primarily outpatient procedure. The underlying indication and extent of the procedure (e.g., removal of the parathyroid gland or a large tumor) may dictate the need for laboratory work or hospitalization. The perianesthesia nurse is responsible for preoperative evaluation of risk, such as airway impacts due to tumor size or the potential for thyroid storm in emergent cases where thyroid hormone may be high going into the procedure. Postsurgically, the patient needs to be closely monitored for bleeding at the procedure site as it may quickly impact vascular and respiratory systems. Further, evaluation of phonation can help identify potential damage to the laryngeal nerve as well as monitoring for symptoms of hypocalcemia as a result of intended or unintended parathyroid removal. Due to the growing rates of outpatient surgery for thyroidectomies, the perianesthesia nurse needs to help the patient and care provider be aware of potential negative outcomes and emergency situations. Several trends in post-thyroidectomy care include lower rates of prophylactic antibiotics, lower rates of drain use, and a press for nonopioid/nonpharmacological pain management in certain postsurgical populations.
Surgery of the thyroid gland was first performed around AD 500, and the first successful removal of a goiter occurred in AD 1000. By the 1800s, numerous thyroidectomies had been performed; however, nearly half of the patients died after surgery as a result of tetany. This morbidity rate was secondary to the removal of the parathyroid glands whose function was not well understood at the time. In the early 1900s, a greater understanding of the role of the parathyroid glands promoted the subtotal thyroidectomy procedure that significantly reduced postoperative complications. In the late 1990s, endoscopic and minimally invasive techniques further reduced some postoperative complications and expanded the number of outpatient cases performed. The type of thyroid surgical procedure chosen depends on the patient’s age, tumor cell type and size, presence of an encapsulated or extracapsular tumor, and any invasion of adjacent structures (Fig. 39.1).
LobectomyRemoval of the entire thyroid lobe.
Lobectomy and IsthmusectomyRemoval of the entire thyroid lobe, isthmus, and pyramidal lobe.
IsthmusectomyRemoval of just the isthmus.
ParathyroidectomyExcision of one or more diseased parathyroid glands.
Subtotal or Near-Total ThyroidectomyRemoval of the thyroid gland with the exception of a small portion retained often on the posterior of the thyroid gland.
Total ThyroidectomyTotal excision of the thyroid gland with the parathyroid glands left intact. Normally, a total thyroidectomy is only performed in patients with medullary malignant disease because total thyroidectomy renders the patient immediately unable to produce any thyroid hormone, requiring thyroid hormone supplementation for the remainder of the patient’s life. Patients who are not a candidate for radioablation may also be considered for thyroidectomy.
Surgery on the thyroid and parathyroid glands is commonly performed with general anesthesia. Regional and local techniques, such as a cervical plexus blockade, are increasing in popularity. An overall trend toward minimally invasive techniques is linked to more outpatient thyroidectomies being performed given the growing evidence of safety.1,2 Appropriate postoperative care for a patient receiving general anesthesia is instituted in the postanesthesia care unit (PACU). Minimally invasive techniques and procedures performed with regional or local anesthesia may minimize recovery requirements for this patient population.
Located just below the hyoid bone, the highly vascular hyperthyroid and parathyroid glands regulate metabolic activity and serum calcium through hormone creation. Surgery is indicated when malignancy and symptoms are present such as hormonal alterations and/or goiter. Surgery is the most typical therapy for malignancy, but radiation, often in the form of radioactive iodine and chemotherapy, may be indicated based on tumor type and staging.
A preoperative euthyroid state is considered the safest strategy for prevention of thyroid storm (see Thyroid Storm later in this chapter). Preoperative and postoperative calcium and vitamin D supplementation can be used to reduce the complications of hypocalcemia. Evaluation of a patient’s voice quality provides the baseline to assess the presence of postoperative laryngeal nerve damage. There is evidence to support dosing patients with dexamethasone preoperatively to prevent postoperative nausea and vomiting (PONV).3
The patient should be placed in the side-lying position to protect the airway when minimally responsive on arrival in the PACU. Once the patient is responsive or if the patient is responsive on admission, a semi-Fowler position of at least 30 degrees elevation is used to promote venous return. The nurse must position the patient with specific attention given to head and neck support to prevent undue tension on the suture line.
The nurse should carefully monitor the airway, respiratory rate, breath sounds, and pulse oximetry. Palpation to assess for crepitus should also be done. A positive finding is an indication of the presence of subcutaneous emphysema. Signs and symptoms of impending respiratory obstruction such as tracheal deviation, stridor, air hunger, or falling oxygen saturations should be reported immediately to the anesthesia provider and surgeon. In rare situations, immediate reintubation or tracheostomy may be necessary; therefore, the associated reintubation or tracheostomy equipment should be readily available for use. Hypertension and transient elevations of blood pressure should be avoided to decrease stress on suture lines and to avoid hematoma and hemorrhage. Prevention and management of heavy coughing, nausea, vomiting, or dry retching is essential.
Pain may be minimal after thyroidectomy and parathyroidectomy when performed on an outpatient basis. Postoperative analgesia requirements are greater in the open procedure population. Small doses of an opioid may be needed in the first 24 hours for patients admitted to a facility, but nonsteroidal anti-inflammatory drugs (NSAIDs) and local anesthesia practices are effective nonopioid alternatives.4,5 Severe pain is an abnormal finding that can indicate unexpected bleeding or nerve damage and is a risk factor for unwanted hypertension (See Evidence-based practice box).
The opioid epidemic has caused health care providers to examine prescribing practices and opioid use, particularly for minor outpatient surgical procedures. Use and need of opioids was retrospectively examined in a cohort of 1702 patients undergoing thyroid and parathyroidectomies before and after initiation of protocols intended to reduce opioid use. The protocol included preoperative education regarding pain management, assessment, and the use of both nonpharmacological and nonopioid interventions. Findings indicated that the new protocol resulted in fewer patients requiring postoperative opioids, fewer homegoing opioids, and patients less likely to call for refills if they did have an opioid prescription at discharge.
The opioid epidemic has required nurses to revisit their personal beliefs, update their patient education practices, and address overprescribing in their practice settings. Nurses greatly contribute to interdisciplinary changes to pre- and postoperative care protocols including the utilization of opioids. Postoperative nursing interventions include ice packs, throat lozenges, acetaminophen, and NSAIDs as opposed to administering opioids. Nurses are in a unique position as patient advocates and educators to provide interventions that can improve patient care and address issues like the opioid epidemic.
Source: Shindo M, Lim J, Leon E, et al. Opioid prescribing practice and needs in thyroid and parathyroid surgery. JAMA Otolaryngol Head Neck Surg. 2018;144:1098–1103.