Care of the thyroid and parathyroid surgical patient

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39 Care of the thyroid and parathyroid surgical patient

Matthew D. Byrne, PhD, RN, CPAN , Joni M. Brady, MSN, RN, CAPA, CLC

Definitions

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).

Parathyroidectomy:  Excision of one or more diseased parathyroid glands.

Subtotal/Partial Thyroidectomy:  Removal of the thyroid gland with the exception of a small portion retained on the opposite side of the thyroid.

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.

Thyroid Lobectomy with Isthmusectomy:  Removal of one lobe of the thyroid and the isthmus that connects the two lobes.

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).

image

FIG. 39-1 Thyroid gland and surrounding anatomic structures.

(From Elisha S, et al: Anesthesia case management for thyroidectomy, AANA J 78(2):152, 2010.)

Anesthesia

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.

Perianesthesia nursing care

Preoperative considerations

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.

Positioning

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.

Cardiopulmonary assessment and care

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 management

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.

Dressings and drains

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.

Evidence-Based Practice

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.

Implications for practice

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.

Source: Morrissey AT, et al: Comparison of drain versus no drain thyroidectomy: randomized prospective clinical trial, J Otolaryngol Head Neck Surg 37:43-47, 2008.

Intake and output

As with any surgical patient, intake and output monitoring is important for the evaluation of cardiovascular stability. Because many thyroid surgeries are performed on an outpatient basis, it is important to ensure that the patient is capable of tolerating oral fluids before discharge. Routine phonation and swallowing evaluations serve to rule out laryngeal nerve damage, which could precipitate aspiration.

Complications

As knowledge of thyroid and parathyroid function and interventional surgical techniques improved, postoperative complication rates decreased and now reportedly occur in less than 1% of patients. Complications are largely attributed to surgeon skill level, type and invasiveness of tumor, anatomic visualization during the procedure, and the patient’s preoperative thyroid state.

Bleeding and airway (respiratory) compromise

As surgical techniques became more refined and less invasive, the risk of postoperative bleeding was reduced significantly. Cardiopulmonary status compromise depends on the technique used and extent of the procedure. Techniques such as an endoscopic approach requiring insufflations can result in arterial or venous injury, hemorrhage, or pneumothorax. Open procedures used for large tumor removal may be more prone to cause hemorrhage and airway compromise. Excessive postoperative bleeding may cause tracheal compression and subsequent airway obstruction, and this finding should be reported to the surgeon immediately.

Respiratory difficulties range from dropping oxygen saturations to stridor (a result of airway obstruction or compromise from bleeding). In cases that involve extensive dissection or insufflations, vocal cord and laryngeal nerve damage, laryngeal edema and pneumothorax can occur. Neck swelling, pain, pressure, fullness in the neck, dysphagia, and dysphonia (hoarse voice) can be specific indications of bleeding or nerve damage and indicate an existing potential for airway or respiratory compromise. Any excess bleeding requires the nurse to initiate immediate reporting to the surgeon.

Recurrent laryngeal nerve injury

The recurrent laryngeal nerve may be injured during surgery because of clamping, compression, severing, or stretching. Unilateral recurrent laryngeal nerve injury can appear as a weak cough and change in voice. In some cases, although the damage actually occurred, no notable signs may be present. Aspiration is another potential risk with this type of injury. Symptoms of bilateral recurrent laryngeal nerve injury can result in life-threatening airway obstruction and may necessitate immediate intervention, including a potential for reintubation and tracheostomy. Nerve injury is generally transient and can be treated with corticosteroids.

Hypoparathyroidism and hypocalcemia

Hypoparathyroidism is a complication that can occur after total thyroidectomy or total parathyroidectomy. The condition can be caused by intentional removal of the parathyroid glands or inadvertent or unavoidable damage during thyroidectomy. This complication manifests as hypocalcemia and is usually transient. Signs and symptoms of hypocalcemia, caused by neuromuscular irritability, rarely occur in the immediate postoperative period, but may appear 24 to 72 hours after surgery. Symptoms include numbness and tingling of the fingers, toes, and area around the mouth (perioral), muscle cramps (tetany), and spasm. If calcium levels are not restored, seizures and laryngeal stridor are imminent.

The assessment of any patient who verbalizes tingling symptoms includes testing for the presence of Chvostek sign (the development of a lip twitch or facial spasm when the cheek is tapped over the facial nerve) and Trousseau sign (carpal spasm development when a blood pressure cuff is applied and the circulation transiently occluded). Laboratory findings, Chvostek sign, and an evaluation of carpopedal spasms (clonus in the feet when dorsiflexed) are preferred over assessing for Trousseau sign, which can sometimes be painful. Definitive treatment involves intravenous administration of calcium. Although both calcium chloride and calcium gluconate may be used, calcium gluconate is preferred for its greater bioavailability and lesser arrhythmogenic potential. When intravenous calcium is administered, it is given via slow push with continuous electrocardiographic monitoring performed before, during, and after the infusion. Early and routine calcium and vitamin D supplementation have been indicated as a useful strategy in the reduction of hypocalcemic complications.6–8

Thyroid storm

Thyroid storm, or thyrotoxic crisis, is a rare complication that can occur after surgical manipulation of a hyperactive thyroid. Rapid diagnosis of the underlying cause for an apparent postoperative hypermetabolic state is crucial for appropriate treatment of the problem. The presence of malignant hyperthermia (another potential cause for postanesthetic hyper-metabolic state) versus thyroid storm must be differentiated, because these disorders have significantly different treatment algorithms.

Ideally, an overactive thyroid is controlled with medication so that the patient arrives in the preoperative setting in a euthyroid state. Thyroid storm more commonly occurs when a patient with hyperthyroidism and thyrotoxicosis is involved in an emergent procedure or in circumstances when inadequate preoperative time is available to normalize thyroid levels. The patient can initially develop fever and tachycardia during surgery and subsequently appear in the postanesthesia setting in a hypermetabolic state that can include agitation, disorientation, hypertension, tachycardia, and heart failure proceeding to shock. Treatment should focus on thyroid level normalization, maintenance of cardiopulmonary integrity through reduction or management of sympathetic output, and reduction of the other signs and symptoms of hypermetabolism, most notably hyperthermia. Treatment generally includes administration of beta blockers, iodine, vasopressors, fluid support, oxygen, salicylates, steroids, and cooling measures.

Infection

Disagreement exists about the need for routine antibiotic administration, because the incidence of postoperative infection in patients who have undergone thyroid and parathyroid surgery is rare.9 Any postoperative infection symptoms should be investigated and treated with appropriate antibiotic therapy and wound care.

Summary

Increased knowledge of thyroid and parathyroid function, and improved and minimally invasive surgical techniques significantly decreased the length of stay and postoperative complication rates in the thyroid surgical population. Surgery on the thyroid and parathyroid glands is commonly performed with general anesthesia, and postoperative nursing care is focused on the recovery of the patient from general anesthesia. Selected minimally invasive procedures performed under local anesthesia minimize postoperative recovery requirements and length of stay, and they are becoming increasingly popular.

Postoperative nursing assessment should focus on the potential for cardiopulmonary compromise owing to sympathetic output related to a hyperthyroid state, hemorrhage, and venous oozing or laryngeal edema. The nurse should proactively address pain management, proper positioning to minimize suture line stress, ongoing assessment of the operative dressing and intake and output status. Although rare, thyroid surgery complications can include inferior or superior laryngeal nerve damage with possible vocal cord paralysis, laryngeal stridor, airway and respiratory compromise, bleeding that causes cervical or neck hematoma requiring surgical evacuation, hypocalcemia, tetany, seizures and mental disturbances, thyroid storm, and infection. Recognition of potential complications and implementation of appropriate and rapid treatment interventions are essential for an optimal postoperative outcome.

References

1. Suri KB, et al. Postoperative recovery advantages in patients undergoing thyroid and parathyroid surgery under regional anesthesia. Semin Cardiothorac Vasc Anesth. 2010;14:49–50.

2. Tuggle CT, et al. Same-day thyroidectomy: A review of practice patterns and outcomes for 1,168 procedures in New York State. Ann Surg Oncol.2011;18:1035–1040.

3. Elisha S, et al. Anesthesia case management for thyroidectomy. AANA J. 2010;78:151–160.

4. Dunlap WW, et al. Thyroid drains and postoperative drainage. Otolaryngol Head Neck Surg 143. 2010:235–238.

5. Morrissey AT, et al. Comparison of drain versus no drain thyroidectomy: Randomized prospective clinical trial. J Otolaryngol Head Neck Surg.2008;37:43–47.

6. Roh JL, et al. Prevention of postoperative hypocalcemia with routine oral calcium and vitamin D supplements in patients with differentiated papillary thyroid carcinoma undergoing total thyroidectomy plus central neck dissection. Cancer. 2009;115:251–258.

7. Roh JL, Park CI. Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy. Am J Surg. 2006;192:675–678.

8. Sabour S, et al. The role of rapid PACU parathyroid hormone in reducing post-thyroidectomy hypocalcemia. Otolaryngol Head Neck Surg. 2009;141:727–729.

9. Moalem J, et al. Patterns of antibiotic prophylaxis use for thyroidectomy and parathyroidectomy: Results of an international survey of endocrine surgeons. J Am Coll Surg.2010;210:949–956.

Resources

AACE/AME Task Force on Thyroid Nodules: American as- sociation of clinical endocrinologists and associazione medici endocrinologi medical guidelines for clinical prac- tice for the diagnosis and management of thyroid nodules, 2020. available at: https://www.aace.com/sites/default/files/ThyroidGuidelines.pdf, March 22, 2012. Accessed

Gal I, et al. Minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: A prospective randomized study. Surg Endosc.2008;22:2445–2449.

Hopkins B, Steward D. Outpatient thyroid surgery and the advances making it possible. Curr Opin Otolaryngol Head Neck Surg. 2009;17:95–99.

Johnson K. Laparoscopic or open removal of parathyroid. Intern Med News. 2005;38:28.

Lee KE, et al. Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach. Surgery. 2010;148:1207–1213.

Mazzaferri EL, et al. Practical management of thyroid cancer: A multidisciplinary approach. New York: Springer; 2010.

McKennis A, Waddington C. Nursing interventions for potential complications after thyroidectomy. available at www.sohnnurse.com/thyroidectomy.html

Muenscher A, et al. The endoscopic approach to the neck: A review of the literature, and overview of the various techniques. Surg Endosc.2011;25:1358–1363.

Noble KA. Thyroid storm. J Perianesthesia Nurs. 2006;21:119–125.

Oertli D, Udelsman R. Surgery of the thyroid and parathyroid glands. New York: Springer, 2007.

Patel M, et al. Fibrin glue in thyroid and parathyroid surgery: Is under-flap suction still necessary. Ear Nose Throat J.2006;85:530–532.

Takesuye D, et al. Practice analysis: Techniques of head and neck surgeons and general surgeons performing thyroidectomy for cancer. Qual Manage Health Care.2006;15:257–262.

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