39 Care of the thyroid and parathyroid surgical patient
Bilateral Subtotal Thyroidectomy: Removal of most of the thyroid tissue in both lobes with a small remnant of thyroid tissue left at the back portion of the thyroid to protect the parathyroid glands and prevent recurrent laryngeal nerve damage (a potential complication associated with total thyroidectomy).
Thyroidectomy: Total 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, thus 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 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 which 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).
(From Elisha S, et al: Anesthesia case management for thyroidectomy, AANA J 78(2):152, 2010.)
Surgery on the thyroid and parathyroid glands is commonly performed with general anesthesia. Regional and local techniques, such as a cervical plexus blockade, are growing in popularity as minimally invasive techniques and the number of outpatient cases grows.1–3 Appropriate postoperative care for a patient receiving general anesthesia is instituted in the postanesthesia care unit. Minimally invasive techniques and those procedures performed with regional or local anesthesia may minimize the recovery requirements for this patient population.
A preoperative euthyroid state is considered the safest strategy for prevention of thyroid storm (see Thyroid Storm). 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.
The patient should be placed in the side-lying position to protect the airway when minimally responsive on arrival in the postanesthesia care unit. 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 in order 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, because 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 some 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. Severe pain is an abnormal finding that can indicate unexpected bleeding or nerve damage, and it is a risk factor for unwanted hypertension.
Postoperative dressings are small, and drains are generally not required. Postoperative drainage is minimal and should not visibly soak through the dressing. Some disagreement persists regarding the use of surgical drains. There are questions regarding whether the presence of a drain causes increased pain, scarring, cost, length of stay, and a drain’s limited ability to identify and prevent hematoma.4,5 Drains may be indicated in the presence of greater intraoperative blood loss or an extensive procedure or when a large space is left after removal of a tumor or goiter.
Debate about drain placement and the associated effects on scarring, infection, hematoma, and length of stay continues for the postthyroidectomy patient population. In a randomized prospective clinical trial, 55 patients requiring thyroidectomy were randomly assigned to drain and no-drain groups. The researchers found statistically significant results demonstrating that the no-drain group had a 1.12-day reduction in hospital stay, a cost savings of $2177 per patient, and no increase in postoperative complications.
Although thyroidectomy patients can arrive with or without surgical wound drains, care outcomes appear to be equivalent or improved in the no-drain population. The presence of a surgical drain in the postthyroidectomy patient should not create a false sense of security regarding potential complications, particularly for the development of hematomas. Vigilance and routine hematoma assessment compose the cornerstone of care for this population.