Rex Stephen S. de Ungria, MD
(Resident-in-Charge)
 B.G.
 45
y/o
 Female
 Date of Admission: May 22, 2019
Vaginal Spotting
1 month PTA
16 days PTA
11 days PTA
• (+) cessation of menses on April 2019
• Took PT reveals negative result
• (+) persistence of above symptoms now acc by
constipation and bloatedness, sought consult and
revealed (+)PT
• TVS-H-mole/molar pregnancy
• Labs: B-Hcg >10,000 IU/ml and HBsAg Reactive
• Sought consult
• Labs done which revealed same result
• Was advised for possible operation
7 days PTA
1 day PTA
• Consulted in our institution with no
subjective complaints
• Dx: G6P5 (5005) Molar Pregnancy 11
1/7 wks AOG
• Possible TAH-BS
• Labs: TSH-0.01(L), FT3-5.99 (H), FT4-2.22
• Given PTU 50mg tab
• (+) Vaginal spotting not asscoiated with
other symptoms hence admitted
ADMISSION
 HEENT:
(-) headache (-) Proptosis
 CARDIOVASCULAR :(-) chest pain (-) easy
fatigability (-) palpitations (-) orthopnea
(-) PND
 RESPIRATORY: (-) cough (-)dyspnea (-)
shortness of breath (-) hemoptysis (-)pleuritic
chest pain
 GIT: (-) changes in bowel habit (-) vomiting
(-) diarrhea (-) melena (-) constipation
 NEURO: (-) loss of consciousness (-) seizures
 GUT:
(-) polyuria (-) urgency (-) frequency (-)
oliguria (-) anuria
 MUSCULOSKELETAL: (-) muscle pain (-)
swelling (-) bone defmormity (-) weakness (-)
atrophy
 ENDOCRINE: (+) heat intolerance (-) cold
intolerance (-) weight gain (-) weight loss (-)
polyuria (-) polydipsia (-) polyphagia
 HEMATOLOGIC: (-) bruisability (-) easy
fatigability (-) pallor
 (+)

Hyperthyroidism (May 2019)
PTU 50mg tab
 (+)
PTB (2017) Completed treatment
 (-) Hypertension
 (-) Bronchial Asthma/COPD
 (-) known allergies
 (+) Prev Incision and Drainage of Abscess left
Breast in 2008 which denies of any
anesthesia complications
 Non
smoker
 Non
alcoholic beverage drinker
 conscious,
coherent, ambulatory
 VS: BP 110/70
HR 94/min RR 18/min
height 5’4’’
weight 46.5 kg
 Pink palpebral conjunctivae, anicteric
sclerae
 No naso-aural discharge, no TPC, tonsils not
enlarged
 Mallampati II, TMD 5cms, MO 4-5cms, (-)
dentures
 Supple neck with good mobility
 SCE,
clear & equal BS
 AP, NRRR, (-) murmurs appreciated
 Flabby soft, abdomen, nontender
 Extremities: pulses full and equal (-) edema
 Neuro Examination: GCS 15 (E4 V5 M6)
 Immunology

TSH- 0.01

FT3- 5.99

FT4- 2.22
and Serology (5/21/19)
 Chemistry








(5/18/19)
FBS – 3.74
BUN – 2.8 mmol/L
Creatinine – 52.40 umol/L
SGPT(ALT) – 16.30
SGOT (AST) – 19.20
Serum K – 4.15 mmol/L
Serum Na – 138.0 mmol/L
Serum Cl – 101.10
 CBC


(5/18/19)
Hemoglobin – 136
Hematocrit – 0.42
 HEMATOLOGY




(5/18/19)
Prothrombin Time - 10.9
Protime Activity - 100%
Activated Partial Thromboplastin Time – 28.6
Bleeding Time - 2.00
 Chest

Minimal hypertrophic degenerative changes of
the thoracic spine otherwise normal chest
 Tumor

Xray (5/17/19)
Markers (5/9/19)
>10,000 mIU/ml
 Serology

(5/9/19)
HbsAg - Reactive
 Given
the very high thyroid hormone levels,
preoperative thyroid storm should be kept in
mind
 There is not enough time available for
optimizing patient’s clinical and biochemical
condition
 ASA
III MAL II
 Medical Problems



H-mole pregnancy
Hyperthyroidism
HBsAg - reactive
Combined Spinal and Epidural
Anesthesia
 Administer

IV fluids
Administer PTU 200-400mg via NGT
 Administer
Hydrocortisone 50-100mg IV or
Dexamethasone 8-12mg/day
 Beta
blockers titrated to achieve heart rate
below 90 beats per minute
• Awake with ongoing IVF D5LR 1L
• BP 135/80; HR 69/min; RR 20/min; SPO2 100%
• Hooked to O2 2-3LPM/NC
Prior to
Inductio
n
9:50AM • VS: BP 100/60 HR 80/min RR 18 SPO2 100%, hooked to O2
3LPM/NC
• LLDP; Asepsis and antisepsis; Local Infiltration w/
Lidocaine 2%;Epidural tap L3 L4 using touhy G18, (+)
Inductio
LORTA, catheter (4cm) threaded cephalad with ease; (-)
n
CSF (-) blood (-) paresthesias preceeded with spinal tap
L4 L5 Quincke SNG 25 (+) CSF clear & free-flowing
(10:12A
M)
• Bupivacaine 0.5% Heavy 15mg, Spinal Level T6, catheter
secured
(10:15A
M10:25am
)
•
•
•
•
VS: BP 130/80 HR 90/min SPO2 100%
Cefuroxime 1.5g IV
Midazolam1.5mg
Hydrocortisone 100mg IV
TAHBS
Started
19mins from
Induction
24mins of the
procedure
44 mins of the
procedure
• VS: BP: 90/60 HR: 65/min RR 18/min SPO2
98% Temp-33.8 C
• BP 80/45mmHg HR 55/min T-33.9 C
• Ephedrine 5mg/IV
• BP 80/40mmHg HR 50/min T-33.9 C
• Ephedrine 5mg/IV
65mins of
the
procedure
159 mins of
the procedure
• BP: 120/70 HR 65/min SPO2 99% T-33.8C
• Levobupivacaine 15mg via epidural catheter, then
10mg after 10 mins, then 25mg after 10 mins
• BP 120/80 HR 60/min SPO2 99%
• Epidural analgesia: Morphine Sulfate 0.2mg
FIRST DOSE given
TAHBS • drowsy to arousable, follow commands
ended
• BP 120/70; HR 68/min; RR 18/min; SPO2 99%
after
179 mins
s/p TAHBS
• Drowsy to
arousable
• BP 120/80 HR
85bpm
• (-)NVE
• SCE, clear BS
Post-op
Orders
• O2 2-3LPM/NC
• IVF: PLR 1L x 8
hours
• Ketorolac
30mg/IV q6
• Paracetamol
600mg IV PRN for
pain
Post-op Orders
• Epidural
Analgesia as ff:
• Morphine SO4
0.2mg in 50cc
PNSS, 10CC q
12 hrs x 3
doses c/o
AROD
At the ward
(12th post-op
hour)
• Conscious,
coherent
• BP110/70 HR 78
• No subjective
complaints
• 2ND Dose of
Morphine 0.2mg
in 10 ml given
via epidural
catheter
At the ward (24th
post op hour)
• Consciou,
coherent
• No subjective
complaints
• BP 90/60 HR 70
• Pain scale: 4/10
• 3RD dose of
Morphine was
not given
At the ward (36th
post-op hour)
• Conscious, coherent
• No subjective
complaints
• BP 90/50 HR 68
• PS: 3/10
• Still 3rd dose of
Morphine was not given.
• Epidural Catheter
remove blue tip intact
• Pain med shifted to oral
by main service
HYPERTHYROIDISM
 Hyperthyroidism
refers to hyperfunctioning
of the thyroid gland, with excessive secretion
of active thyroid hormones.
 result
from one of three pathologic
processes:
1. Graves disease
2. Toxic multinodular goiter
3. Toxic adenoma
 Signs
and Symptoms:
Regardless of the cause, the signs and
symptoms of hyperthyroidism are those of a
hypermetabolic state. The patient is anxious,
restless, and hyperkinetic and may be
emotionally unstable.
 Signs


and Symptoms:
Wasting, weakness, and fatigue of the proximal
limb muscles are common.
The patient usually complains of extreme fatigue
but an inability to sleep.
 Signs




and Symptoms:
Increased bone turnover and osteoporosis may
occur.
A fine tremor of the hands and hyperactive
tendon reflexes are common.
Weight loss despite an increased appetite occurs
secondary to increased calorigenesis.
Bowel movements are frequent and diarrhea is
not uncommon.
 The
cardiovascular system is most
threatened by hypermetabolism of peripheral
tissues, increased cardiac work with
tachycardia, dysrhythmias (commonly atrial)
and palpitations, a hyperdynamic circulation,
increased myocardial contractility and
cardiac output, and cardiomegaly.
 The
cardiovascular system is most
threatened by:
•
•
•
•
•
•
hypermetabolism of peripheral tissues
increased cardiac work with tachycardia
dysrhythmias (commonly atrial)
palpitations
hyperdynamic circulation
increased myocardial contractility and cardiac
output
cardiomegaly
•
Graves disease
•
•
•
•
toxic diffuse goiter
etiology is unknown
occurs in females (female/male ratio is 7:1)
between the ages of 20 and 40 years
appears to be a systemic autoimmune disease
•
Graves disease
•
caused by thyroid-stimulating antibodies that
bind to TSH receptors in the thyroid, activating
adenylcyclase and stimulating thyroid growth,
vascularity, and hypersecretion of T4 and T3
•
thyroid is usually diffusely enlarged, becoming
two to three times its normal size
•
Graves disease
•
•
ophthalmopathy occurs in 30% of cases and may
include upper lid retraction, a wide-eyed stare,
muscle weakness, proptosis, and an increase in
intraocular pressure
Diagnosis is confirmed by the presence of
thyroid-stimulating antibodies in the context
of a low TSH level and elevated T4 and T3 levels
•
Toxic multinodular goiter
•
•
•
•
arises from long-standing simple goiter
occurs mostly in patients older than age 50
may present with extreme thyroid enlargement
that can cause dysphagia, globus sensation, and
possibly inspiratory stridor from tracheal
compression
this is common when the mass extends into the
thoracic inlet behind the sternum
•
Toxic multinodular goiter
•
•
In severe cases, superior vena cava obstruction
syndrome may also be present
diagnosis is confirmed by a thyroid scan
demonstrating “hot” patchy foci throughout the
gland or one or two “hot” nodules
•
Treatment
•
first line of treatment for hyperthyroidism is an
antithyroid drugs
•
•
Methimazole
Propylthiouracil (PTU)
•
Treatment
•
•
•
•
interfere with the synthesis of thyroid hormones by
inhibiting organification and coupling
PTU has the added advantage of inhibiting the
peripheral conversion of T4 to T3
Euthyroid state can almost always be achieved in
6–8 weeks with either drug if a sufficient dosage is
used
•
Treatment
•
•
•
Iodide in high concentrations inhibits release of
hormones from the hyperfunctioning gland
Inorganic iodide inhibits iodide organification and
thyroid hormone release
This phenomenon is known as the
WOLF-CHAIKOFF EFFECT
•
Treatment
•
High concentrations of iodide decrease all
phases of thyroid synthesis and release and
result in reduced gland size and possibly a
decrease in vascularity
•
Treatment
•
effects occur immediately but are short-lived
•
reserved for preparing hyperthyroid patients for
surgery, managing patients with actual or
impending thyroid storm, and treating patients
with severe thyrocardiac disease
•
Treatment
•
There is no need to delay surgery in a patient
with otherwise well-controlled thyrotoxicosis
in order to initiate iodide therapy
•
•
Treatment
IODIDE
•
•
administered orally as a saturated solution of
potassium iodide (SSKI)
3 drops PO every 8 hours for 10–14 days
•
Treatment
•
radiographic contrast dye ipodate or iopanoic
acid (0.5–3.0 g every day) contains iodide and
demonstrates beneficial effects similar to those
of inorganic iodide
•
inhibits the peripheral conversion of T4 to T3
•
antagonize thyroid hormone binding to receptors
•
Treatment
•
Antithyroid drug therapy should precede
initiation of iodide treatment, because
administration of iodide alone will increase
thyroid hormone stores and exacerbate the
thyrotoxic state
•
Treatment
•
What about patients who are allergic to iodide?
•
Lithium carbonate 300 mg PO every 6 hours
may be given in place of potassium iodide or
ipodate
•
Treatment
•
β-Adrenergic antagonists
•
•
•
may relieve signs and symptoms of increased
adrenergic activity such as anxiety, sweating, heat
intolerance, tremors, and tachycardia
Propranolol offers the added features of impairing
the peripheral conversion of T4 to T3 over 1-2
weeks
Propanolol given over 12-24 hours decreases
tachycardia, heat intolerance, anxiety and tremor
•
Treatment
•
Ablative therapy with radioactive iodine 131
(131I) or surgery
•
is recommended for patients with Graves disease for
whom medical management has failed, as well as for
patients with toxic multinodular goiter or a toxic
adenoma
•
Treatment
•
•
•
Hyperthyroidism during pregnancy is treated
with low dosages of antithyroid drugs
these drugs do cross the placenta and can cause
fetal hypothyroidism
But if the mother remains euthyroid while
taking small dosages of an antithyroid drug, the
occurrence of fetal hypothyroidism is rare
•
Treatment
•
Radioactive iodine treatment is contraindicated
during pregnancy, as is oral iodide therapy,
because it can cause fetal goiter and
hypothyroidism
•
Thyroid storm occurring in pregnancy is managed
in the same way as in nonpregnant patients
•
MANAGEMENT OF ANESTHESIA
•
hyperthyroid patients undergoing surgery,
Euthyroidism should definitely be established
preoperatively
•
Elective cases should wait a substantial time
(6–8 weeks) for the anti thyroid drugs to become
effective
•
MANAGEMENT OF ANESTHESIA
In emergency cases:
•
•
•
•
Use of an IV β-blocker, ipodate, glucocorticoids, and
PTU is usually necessary.
No IV preparation of PTU is available so it must be
taken orally, via a nasogastric tube, or rectally
Glucocorticoids (dexamethasone 2 mg IV every 6
hours) should be administered to decrease hormone
release and reduce the peripheral conversion of T4 to
T3
•
MANAGEMENT OF ANESTHESIA
•
Evaluation of the upper airway for evidence of
tracheal compression or deviation caused by a
goiter is an important part of the preoperative
evaluation
•
MANAGEMENT OF ANESTHESIA
•
Establishment of adequate anesthetic depth is
extremely important to avoid exaggerated
sympathetic nervous system responses
•
MANAGEMENT OF ANESTHESIA
•
Drugs that stimulate the sympathetic nervous
system should be avoided:
•
•
•
•
•
Ketamine
Pancuronium
Atropine
Ephedrine
Epinephrine
•
MANAGEMENT OF ANESTHESIA
•
For maintenance of anesthesia, any of the
potent inhalation agents may be used
•
A concern in hyperthyroid patients is organ
toxicity secondary to an increase in drug
metabolism
•
Hyperthyroid patients may have co-existing
muscle disease (e.g. myasthenia gravis) with
reduced requirements for the nondepolarizing
muscle relaxants; therefore careful titration is
required
•
MANAGEMENT OF ANESTHESIA
•
For treatment of intraoperative hypotension, a
direct-acting vasopressor (phenylephrine) is
preferred
•
Ephedrine, epinephrine, norepinephrine, and
dopamine should be avoided or administered in
extremely low doses to prevent exaggerated
hemodynamic responses
•
MANAGEMENT OF ANESTHESIA
•
Regional anesthesia can be safely performed and
in fact may be a preferred technique
•
Epinephrine-containing local anesthetic solutions
should be avoided
•
Removal of the thyrotoxic gland does not mean
immediate resolution of thyrotoxicosis
•
MANAGEMENT OF ANESTHESIA
•
The half-life of T4 is 7–8 days
•
β-blocker therapy may need to be continued in
the postoperative period
•
THYROID STORM
•
a life-threatening exacerbation of
hyperthyroidism precipitated by trauma,
infection, medical illness, or surgery
•
THYROID STORM
•
can present with similar intraoperative and
postoperative signs and symptoms like Malignant
Hyperthermia such as:
•
•
•
hyperpyrexia
tachycardia
hypermetabolism
•
THYROID STORM
•
most often occurs in the postoperative period
in untreated or inadequately treated
hyperthyroid patients after emergency surgery
•
Patients manifest extreme anxiety, fever,
tachycardia, cardiovascular instability, and
altered consciousness
•
THYROID STORM
•
Treatment includes rapid alleviation of
thyrotoxicosis and general supportive care
•
Dehydration is managed with IV administration
of glucose-containing crystalloid solutions
•
Fever is countered by cooling measures such as
cooling blanket, ice packs and administration of
cool humidified oxygen
•
THYROID STORM
•
β-Blockers should be titrated to decrease heart
rate to less than 90 beats per minute
•
Dexamethasone 2 mg every 6 hours or cortisol
100–200 mg every 8 hours can be used to
decrease hormone release and conversion of T4
to T3
•
THYROID STORM
•
•
Antithyroid drugs (PTU 200–400 mg every 8
hours)
administered through a nasogastric tube, orally,
or rectally
•
THYROID STORM
•
If circulatory shock is present, IV administration
of a direct vasopressor (phenylephrine) is
indicated
•
β-adrenergic blocker or digitalis is recommended
for atrial fibrillation accompanied by a fast
ventricular response
•
THYROID STORM
•
Serum thyroid hormone levels generally return
to normal within 24–48 hours, and recovery
occurs within 1 week
•
The mortality rate for thyroid storm remains
surprisingly high at approximately 20%.
Good Evening!!!