Parathyroidectomy

Anesthesia Implications

Position: Supine, arms tucked, head slightly extended
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: No
Blocks: Superficial Cervical Plexus

Check Thyroid Levels – Patient should be as near euthyroid as possible (0.4 to 4.0 mIU/L, HR less than 80 bpm, no hand tremor).

Airway Checks – Check for tracheal deviation as this may be a good indication of airway obstruction. Ask if the patient has dysphagia, stridor, or shortness of breath when changing positions. Stridor occurs when there's 50% compression. Check for neck veins that are distended and do not change with respiration – this would be an indication that the patient may have SVC obstruction. Vocal cord dysfunction may be present – ensure documentation of preoperative state (this is best confirmed/diagnosed by an ENT surgeon).

NSAIDS – Some suggest preoperative NSAIDs prior to surgery, but postoperative bleeding may be blamed on this – check with the surgeon.

Approach – GETT, standard induction. Avoid taping the ETT anywhere close to the neck. A short-acting paralytic agent like succinylcholine is preferred exclusively for intubation as nerve monitoring will be used. Protect the face/eyes – the surgeons are working on the neck and often forget that they are leaning on the face. Anticipate a shoulder roll for head/neck extension.

Intraoperative Nerve Monitoring – A specialized endotracheal tube (ETT) – NIMs ETT – is positioned to have electrodes directly contact the vocal cords on either side. This aids in safeguarding the recurrent laryngeal nerve from injury during neck dissections near the inferior thyroid artery. For this reason, you will avoid the use of long-term paralytics (e.g. Rocuronium).

Parathyroid Samples – Arms will be tucked. Make sure you have a working IV/A-line for serial lab draws (PTH levels) after tucking.

Reduce Airway Inflammation – Dexamethasone 8 mg IV is commonly administered to reduce airway inflammation.

PONV Prophylaxis – Make sure to cover for PONV. Nausea and vomiting can create additional complications if not controlled.

Emergence/Extubation – Minimize coughing. Upon emergence, measures such as deep extubation are typically employed to prevent coughing. Extubate with the patient sitting up to reduce venous compression. The primary fear is hemorrhage – if the patient begins to bleed in the operative area, it may cause airway obstruction postoperatively. This is the primary reason the patient is monitored in the hospital overnight.

Postoperative Signs of Bleeding – Any indication of bleeding/hematoma is an EMERGENCY. Contact surgeon immediately and prepare for reintubation.

Postoperative Hypocalcemia – Watch postoperatively for signs of hypocalcemia (neuromuscular excitability, tingling around the mouth, tetany, ventricular arrhythmias). Treatment includes 10% calcium gluconate over 3 min (calcium chloride will cause tissue necrosis of infiltration occurs).

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Parathyroidectomy, the sole definitive treatment for primary hyperparathyroidism (PHPT), and is indicated for all symptomatic patients. Predominantly, patients have a single parathyroid adenoma, while about 10% may have double adenomas, and a minimal percentage exhibit hyperplasia of all four glands. Symptoms mandating parathyroidectomy include polydipsia, polyuria, nephrolithiasis or nephrocalcinosis, hypercalciuria (greater than 400 mg/dL over 24 hours), compromised renal function (GFR less than 60 mL/minute), osteoporosis (bone density less than -2.5), fragility fractures, pancreatitis, peptic ulcer disease, gastroesophageal reflux, and neurocognitive dysfunction or neuropsychiatric symptoms attributed to PHPT.