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Nonthyroid surgery in the patient with thyroid disease

Ellen F Manzullo, MD, FACP
Douglas S Ross, MD
Section Editor
David S Cooper, MD
Deputy Editor
Jean E Mulder, MD


Thyroid disease is common; the prevalence is higher in women and with increasing age [1,2]. In a cross-sectional study of participants in a health fair, the proportion of subjects with an elevated thyroid-stimulating hormone (TSH) level increased with age and ranged from 4 to 21 percent in women and 3 to 16 percent in men [3]. These findings suggest that a significant number of patients who are undergoing surgery may have concomitant thyroid disease.

On the other hand, patients who are seriously ill often have abnormal thyroid function tests that may or may not be clinically significant [4]. These patients need to be distinguished from those who have clinically significant thyroid dysfunction.

The issues surrounding thyroid disease in patients undergoing nonthyroid surgery are discussed here. A brief review of thyroid function in seriously ill patients is presented first, followed by specific issues in patients with hypothyroidism and hyperthyroidism. It should be noted that most patients who have well compensated thyroid disease do not need special consideration prior to surgery. The majority of the discussion applies to patients who have a newly diagnosed thyroid disorder around the time of surgery.

The management of patients with hyperthyroidism undergoing thyroid surgery is reviewed separately. (See "Surgical management of hyperthyroidism", section on 'Preoperative preparation'.)


Assessment of thyroid function in hospitalized or seriously ill patients can be difficult. The majority of hospitalized patients have a low serum triiodothyronine (T3) concentration; from 15 to 20 percent of hospitalized patients and up to 50 percent of patients in intensive care units have low serum thyroxine (T4) concentrations (low T4 syndrome). The serum thyroid-stimulating hormone (TSH) concentration may also be low (figure 1). Abnormalities in the T3 concentration have been noted in patients undergoing elective or emergency surgery, independent of the type of anesthesia.


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Literature review current through: Sep 2016. | This topic last updated: Apr 10, 2015.
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  1. Rallison ML, Dobyns BM, Meikle AW, et al. Natural history of thyroid abnormalities: prevalence, incidence, and regression of thyroid diseases in adolescents and young adults. Am J Med 1991; 91:363.
  2. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995; 43:55.
  3. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med 2000; 160:526.
  4. Spencer C, Eigen A, Shen D, et al. Specificity of sensitive assays of thyrotropin (TSH) used to screen for thyroid disease in hospitalized patients. Clin Chem 1987; 33:1391.
  5. Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism. Endocrinol Metab Clin North Am 2003; 32:503.
  6. Abbott TR. Anaesthesia in untreated myxoedema. Report of two cases. Br J Anaesth 1967; 39:510.
  7. Kim JM, Hackman L. Anesthesia for untreated hypothyroidism: report of three cases. Anesth Analg 1977; 56:299.
  8. Appoo JJ, Morin JF. Severe cerebral and cardiac dysfunction associated with thyroid decompensation after cardiac operations. J Thorac Cardiovasc Surg 1997; 114:496.
  9. CATZ B, RUSSELL S. Myxedema, shock and coma. Seven survival cases. Arch Intern Med 1961; 108:407.
  11. Ragaller M, Quintel M, Bender HJ, Albrecht DM. [Myxedema coma as a rare postoperative complication]. Anaesthesist 1993; 42:179.
  12. Weinberg AD, Brennan MD, Gorman CA, et al. Outcome of anesthesia and surgery in hypothyroid patients. Arch Intern Med 1983; 143:893.
  13. Ladenson PW, Levin AA, Ridgway EC, Daniels GH. Complications of surgery in hypothyroid patients. Am J Med 1984; 77:261.
  14. Park YJ, Yoon JW, Kim KI, et al. Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2009; 87:1846.
  15. Sherman SI, Ladenson PW. Percutaneous transluminal coronary angioplasty in hypothyroidism. Am J Med 1991; 90:367.
  16. Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone reduction on perioperative outcome. Anesth Analg 1997; 85:30.
  17. Drucker DJ, Burrow GN. Cardiovascular surgery in the hypothyroid patient. Arch Intern Med 1985; 145:1585.
  18. Myerowitz PD, Kamienski RW, Swanson DK, et al. Diagnosis and management of the hypothyroid patient with chest pain. J Thorac Cardiovasc Surg 1983; 86:57.
  19. Frost L, Vestergaard P, Mosekilde L. Hyperthyroidism and risk of atrial fibrillation or flutter: a population-based study. Arch Intern Med 2004; 164:1675.
  20. Adlerberth A, Stenström G, Hasselgren PO. The selective beta 1-blocking agent metoprolol compared with antithyroid drug and thyroxine as preoperative treatment of patients with hyperthyroidism. Results from a prospective, randomized study. Ann Surg 1987; 205:182.
  21. Vickers P, Garg KM, Arya R, et al. The role of selective beta 1-blocker in the preoperative preparation of thyrotoxicosis: a comparative study with propranolol. Int Surg 1990; 75:179.
  22. Feek CM, Sawers JS, Irvine WJ, et al. Combination of potassium iodide and propranolol in preparation of patients with Graves' disease for thyroid surgery. N Engl J Med 1980; 302:883.
  23. Geffner DL, Hershman JM. Beta-adrenergic blockade for the treatment of hyperthyroidism. Am J Med 1992; 93:61.
  24. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993; 22:263.
  25. Das G, Krieger M. Treatment of thyrotoxic storm with intravenous administration of propranolol. Ann Intern Med 1969; 70:985.
  26. Woeber KA. Thyrotoxicosis and the heart. N Engl J Med 1992; 327:94.