Total Thyroidectomy
Patient phenotype
Female > male 4:1, range 30-70. Indications: thyroid cancer, large goiter, hyperthyroidism (Graves) refractory to medical therapy. Patient should be euthyroid before surgery (or risk thyroid storm intraop).
Procedure
Transverse cervical 'collar' incision. Both lobes mobilized, recurrent laryngeal nerves identified, parathyroids preserved, vessels ligated. ~90-180 min. Optional intraop nerve monitoring.
Anesthetic plan
GETA. Specialized ETT with electrodes (NIM tube — neural integrity monitor) for RLN monitoring. Smooth emergence essential — coughing/bucking risks hematoma.
Setup
- ·Standard ASA monitors
- ·Two PIVs
- ·NIM ETT (size 6.0-7.0 typical female; positioned at vocal cords for RLN monitoring)
- ·Shoulder roll (extends neck for surgical access)
- ·Have airway emergency kit at bedside (cric set) — risk of post-op airway compromise
Biggest concerns by phase
Verify euthyroid state — thyroid storm risk if not
Hyperthyroid patients should be euthyroid before elective surgery. Methimazole/PTU 6-8 weeks pre-op + propranolol last week. Free T4, TSH normal. If emergent surgery on hyperthyroid: pretreat with propranolol, hydrocortisone, PTU, iodine.
NIM tube placement + verification
NIM tube has electrodes that contact vocal cords. Position via direct laryngoscopy OR videoscope; electrodes must touch the cords. Verify with neuromonitoring tech before drape. Avoid lubricants over electrodes (signal loss).
RLN avoidance — DO NOT use long-acting NMB
Surgeon needs to test nerve integrity by stimulating during dissection. Long-acting NMB blocks the response. Plan: intubation dose only, then no further NMB; OR rocuronium reversed with sugammadex prior to nerve monitoring; OR remifentanil-based maintenance.
Thyroid storm — rare but emergent
Hyperthermia, tachycardia, HTN, agitation, sometimes CV collapse. Treat: cooling, propranolol 1-2 mg IV titrated, hydrocortisone 100 mg IV, PTU 600 mg loading via NG, iodine (Lugol's) to stop hormone release. ICU after.
Smooth emergence — no coughing/bucking on tube
Coughing → venous congestion → hematoma in surgical bed → airway compromise. Lidocaine 1-1.5 mg/kg pre-extubation. Deep extubation if airway favorable. Awake but smooth alternative.
Hematoma → airway emergency, hypocalcemia, hoarseness
Post-thyroid hematoma can compress trachea — visible neck swelling, stridor, dyspnea. EMERGENCY: open wound at bedside, return to OR. Hypocalcemia from parathyroid devascularization (24-48h delayed): tingling, Chvostek/Trousseau, muscle spasm. Hoarseness from RLN injury (transient or permanent).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your thyroidectomy patient is in PACU 2 hours post-op. Nurse calls — patient is anxious, has new neck swelling, and is having difficulty breathing. SpO₂ 90% on 4L NC. What's happening and what do you do?
What an examiner probes for
- ▹Recognizes neck hematoma compressing airway
- ▹EMERGENCY: open the wound at bedside (release pressure), call surgeon, prep for OR
- ▹Airway management: anticipate difficult intubation due to swelling, prepare cric kit
- ▹Communication: surgeon, anesthesia attending, PACU charge
Sources
- Miller's Ch 66
- AAES Thyroid Surgery Guidelines
Anatomy reference
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