1. ANESTHETIC MANAGEMENT OFHYPERTHYROID PATIENT POSTED FORTHYROID SURGERYSPEAKER :-Dr.RAVINDRA SINGH CHOUHANMAHATMA GANDHI MEDICAL COLLEGE-2005JAIPUR

2. Introduction An intimate knowledge of theanatomy, physiology,pathophysiology, pharmacology, and specific issues related to anesthesiacase management for thyroidectomy is essentialto provide high-quality care. Airway management may be difficult despite anormal airway examination due to impingementof a thyroid mass on the laryngeal and trachealstructures. Anesthetists must be prepared to useemergency airway adjuncts in case a patientcannot be ventilated or intubated. Because sympathetic nervous systemhyperactivity is associated with increasedamounts of thyroid hormone, it is essential thatall patients having an elective thyroidectomy pt.be in a euthyroid state before surgery 3. HISTORY Thyroid disease has been long recognized: goitres were firstdescribed by the Chinese in 2700 BC. Thyroid surgery was first described in the 12th Century, but formany years the operations were prone to complications. In the twelfth and thirteen centuaries, the school of Saleno inItaly was cradle of thyroid surgery. At that time goitres wereremoved using horrific-sounding instruments such as setons, hotirons, stypics and asphodel powder. The american surgeon William Halsted could trace accounts ofonly 8 operations in which the scalpel was used between 1596and 1800 . However , the advances of anesthesia , antisepsisand haemostasis allowed surgeons , such as Billroth andKocher to perform many more thyroid operations with reducedmortality, In the 1849. Nikolai of St. Petersburg was the first touse General anesthesia for thyroid operation. He used ether on a girl of 17 yr whose goitre was causingtracheal compression. 4. HISTORY Thomas Peel performed his first thyroidectomy in 1907 underlocal anesthetic. 5. BASIC OF THYROID GLANDPHYSIOLOGY The thyroid gland secretes two principal hormones THYROXINE(T3) AND TRIIODOTHYROXINE (3). These major metabolic hormone are required for homeostasis of allcell and influences cell differentiation ,growth , and metabolism. Follicular cells synthesize/secrete thyroid hormones (T4, T3)when stimulated by TSH, low iodide levels, iodide uptake. Regulated by negative feedback loop of hypothalamus-anteriorpituitary-thyroid initiated by TRH causing TSH release. 6. The thyroid gland is the only source of T4. It secretes approx. 70-90 mcg of T4 / day. The total daily production rate of T3 is about 15-30 mcg. About 80% of circulating T3 comes from de-iodination of of T4 inperipheral tissuses. About 20 % comes from direct thyroidsecretion. T4 is biologically inactive untill converted to T3. Activation occurs with 5iodination of the outer ring of T4. 7. Definition Thyrotoxicosis refers to the hypermetabolicclinical syndrome due to raised serum thyroidhormones levels. It may be because ofhyperthyroidism,inflamation of thyroidgland,ingestion of exogenous thyroidhormones. Hyperthyroidism is a type/condition ofthyrotoxicosis in which accelarated thyroidhormones biosynthesis and secretion by thethyroid gland causes thyrotoxicosis9 8. HYPERTHYROIDISM Hyperthyroidism refers to hyperfunctioning of the thyroid glandwith excessive secretion of active thyroid hormones. The majority of cases (i.e., 99%) of hyperthyroidism result fromone of three pathologic processes: Graves disease, Toxic multinodular goiter, Toxic adenoma. Regardless of the etiology, the signs and symptoms ofhyperthyroidism are those of a hypermetabolic state. Hyperthyroidism is the cause of Thyrotoxicosis in many patients. When hyperthyroidism occurs, the follicular cells of thethyroid produce 5 to 15 times the normal amount of thyroidhormone. Hyperthyroidism occurs in 1% to 2% of women andin approximately 0.1% to 0.2% of men. 9. HYPERTHYROIDISM It is of two types;-Primary is when the pathology is withinthe gland .Secondary when the thyroid gland isstimulated by excessive thyroid-stimulating hormone in the circulation. 10. CAUSES12 11. DifferencesPrimary SecondaryGoitre is diffuse, vascular. NodularOnset-abrupt Insidious.Symptoms appear 1st then thyroidswellingThyroid swelling appears 1st.More severe Less severeCVS rare involvement Present with CCF or AFCNS commonly involved Rarely involvedEye signs & exophthalmos arecommon.Eye signs rare13 12. SIGNS AND SYMPTOMS Thyroid hormone has an essential role in metabolism;therefore, the signs and symptoms of hyperthyroidism reflectsa generalized hypermetabolism. 13. Central nervous systemmanifestations Hyperactivity, nervousness & irritability easy fatigability Insomnia & impaired concentration. Fine tremor. Hyperreflexia, muscle wasting &proximal myopathy without fasciculation. Hypokalemic periodic paralysis15 14. CardiovascularManifestation:16 15. Sinus tachycardia/supraventricular tachycardiapalpitations The high cardiac output bounding pulse Systolic hypertension widened pulse pressure. Aortic systolic murmur Worsening of angina or heart failure Atrial fibrillation is more common in patients >50years.17 16. Skin & Nail Manifestations Warm and moist skin Sweating & Heatintolerance Palmarerythema, onycholysis, pruritus, urticaria & diffusehyperpigmentation Hair texture fine Diffuse alopecia occurs in 18 17. Thyroid dermopathy occursin