Nonthyroid surgery in the patient with thyroid disease
- Ellen F Manzullo, MD, FACP
Ellen F Manzullo, MD, FACP
- Professor of Medicine
- University of Texas
- MD Anderson Cancer Center
- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
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 . 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 . 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'.)
THYROID FUNCTION IN SERIOUSLY ILL OR HOSPITALIZED PATIENTS
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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- THYROID FUNCTION IN SERIOUSLY ILL OR HOSPITALIZED PATIENTS
- IS PREOPERATIVE MEASUREMENT OF TSH NECESSARY?
- Surgical outcomes
- - Subclinical hypothyroidism
- - Moderate (overt) hypothyroidism
- - Severe hypothyroidism
- - Suspected hypothyroidism
- - Cardiovascular surgery
- - Postoperative
- - Preoperative preparation for urgent surgery
- Beta blockers
- Thionamides and iodine
- - Intraoperative and postoperative concerns
- Thyroid storm
- SUMMARY AND RECOMMENDATIONS