Preparation For Thyroidectomy Research Articles

The evaluation of simultaneous combined surgery of the heart and thyroid - own experience

Background: Patients referred for cardiac surgery usually also have other comorbidities. These include thyroid disease, which is relatively common in patients with heart problems. Objective: The aim of the study was to evaluate the feasibility of combined cardiac surgery and thyroidectomy. Material and methods: Six patients (age range: 54-74 years) qualified for elective, simultaneous surgeries on the heart and the thyroid were included in the study. In preparation for thyroidectomy, three patients were diagnosed with diseases requiring cardiac surgery. Two patients, initially referred for coronary artery bypass surgery in one case, and surgery for recurrent fluid in the pericardial sac with concomitant mitral and tricuspid valve regurgitation and atrial fibrillation in the other, were diagnosed in large hyperactive goitre. The last patient with a history of oncology (lung tumour), admitted to the Department of Cardiology due to a heart attack, had a CT scan of the chest, which revealed retrosternal goitre narrowing the lumen of the trachea to 9 mm. All patients underwent combined heart and thyroid operation and were discharged home 8-27 days after surgery. Conclusions: Although preoperative qualification requires a very cautious and individual approach, simultaneous surgeries in patients requiring thyroid and heart interventions are expedient and should be promoted.

Pulse methylprednisolone as preparation for thyroidectomy for drug-resistant amiodarone-induced thyrotoxicosis

Pulse methylprednisolone as preparation for thyroidectomy for drug-resistant amiodarone-induced thyrotoxicosis

SUN-509 Plasmapheresis Treatment of Thyrotoxicosis in Pregnancy for Preparation of Thyroidectomy

Introduction: Thyrotoxicosis in pregnancy presents the challenge of maintaining a normal level of maternal free thyroid hormone, while minimizing adverse drug effects, obstetric complications, and the risk fetal hypothyroidism.Propylthiouracil is used for treatment in the first trimester with thyroidectomy typically performed in the second trimester if PTU/ MTZ are intolerable or if thyrotoxicosis persists. When thyroidectomy is indicated, thyroid hormone levels must be normalized prior to the operation, as there is risk of thyroid storm that can occur during and up to several hours postoperatively. In such cases, preoperative plasmapheresis may be considered. Case Presentation: We present a 24 year old G2P0101 Hispanic female who reported to the ED with throat pain, chills, tachycardia, and shortness of breath who was found to have a TSH less than 0.005, free T4 3.15, elevated alkaline phosphatase, and an incidentally discovered early pregnancy approximately 4 - 6 weeks gestation. Medical history includes hyperthyroidism with over ten hospitalizations for thyrotoxicosis within the last three years and preterm delivery during her first pregnancy. A recent thyroid biopsy in 2017 showed a benign multinodular goiter. She had been taking methimazole and current CT of the neck demonstrated marked thyroid goiter with mild tracheal narrowing and mild tonsillitis. She was discharged on propylthiouracil 100 mg TID, metoprolol 25 mg TID, and augmentin 875 mg BID with the goal of decreasing her free T4 and T3 in preparation for thyroidectomy. Four days later, the patient returned to the ED with similar symptoms. Labs revealed TSH 0.001, free T4 3.70, FreeT3 15.1 WBC 3.1, platelets 103, and elevated total bilirubin, transaminases, and alkaline phosphatase. EKG demonstrated sinus tachycardia with minimal diffuse ST depression. Ultrasound showed a 0.34 cm round hypoechoic focus in the endometrial cavity without a fetal pole or cardiac activity. Chest X-ray demonstrated minor bibasilar atelectasis. The patient was admitted and PTU was discontinued due to leukopenia and elevated transaminases. Dexamethasone was started and metoprolol was continued.Total thyroidectomy was planned for when free T4 less 2.0 The patient received two treatments of plasmapheresis, which decreased free T4 to 2.11 and then to 1.40. The thrombocytopenia and transaminitis resolvedA total thyroidectomy was performed and well tolerated. patient had full term pregnancy, uneventful delivery while on thyroid hormone replacement. Conclusion: Preoperative plasmapheresis can be considered for the normalization of free T4 if thionamides fail or cannot be tolerated. This case demonstrates the successful management of thyrotoxicosis with plasmapheresis in the first trimester of pregnancy.to Our knowledge Plasmapheresis was not used before in Pregnancy in preparation for thyroidectomy.

SUN-503 Thyroid Storm Followed by ATD Induced Agranulocytosis in Late Pregnancy: A Management Dilemma

Background:Management of Graves’ disease (GD) in pregnancy presents challenges. Thionamide Antithyroid drugs are the treatment for GD hyperthyroidism with goal of achieving mild but persistent hyperthyroidism and avoiding over-treatment in pregnancy. ATD Induced Agranulocytosis is a rare but serous side effect and presents management dilemmas.Clinical Case:A 37-year-old woman with history of Graves’ disease was admitted to our hospital at gestational age of 34 weeks with fever, palpitations and diarrhea. Burch-Wartofsky Point Scale was 35 concerning for impending thyroid storm. She had been diagnosed with hyperthyroidism 6 weeks into her pregnancy, initially treated with PTU which was then changed to methimazole in 2nd trimester. A work up for infection and PE was negative. Non-compliance was suspected, methimazole was resumed, and hydrocortisone and propranolol were added. After 2 days, her vital signs and free hormone levels normalized. Her methimazole dose was decreased and she was discharged home in a stable condition.Five days after her discharge, she presented with sore throat, fever and chills. She had an absolute neutrophil count (ANC) of 0 and a positive rapid strep test. ATD Induced Agranulocytosis was suspected. Her labs showed elevated fT3 of 4.5(nl 1.7–3.7), normal fT4 and suppressed TSH with <0.01(nl 0.3–4.9). A CT scan of the neck showed no evidence of retropharyngeal or thyroid abscess. Methimazole was stopped and she was started on glucocorticoids (initially betamethasone for fetal lung maturity, then switched to prednisone) and cholestyramine. She was also started on Cefepime and G-CSF for her neutropenia. A thyroid ultrasound showed enlarged and hypervascular gland. TSI was 157%(nl. <122%), and thyroglobulin 155 ng/ml (nl. <33 ng/ml). After 4 days, her ANC started to recover. Simultaneously, she started to show worsening thyrotoxicosis but remined hemodynamically stable. A decision to induce labor was then made and was successfully done on the 6th day of her admission. Post-delivery, PTU was started at low dose along with SSKI to prepare her for total thyroidectomy which was done on day 3 post-delivery. Post-thyroidectomy, she had an uncomplicated course and was discharged on levothyroxine. Her child did well with no evidence of thyroid disease.Conclusion:We present a unique case of thyrotoxicosis in late pregnancy complicated by ATD Induced Agranulocytosis. Given the high risk of thyroid surgery during pregnancy, our multi-disciplinary team approach opted for labor induction, followed by preparation for thyroidectomy and subsequent surgery. Individualization of management approach using a multi-disciplinary team with emphasis on maternal and fetal well-being is of paramount importance with such challenging presentations.

The Value of Color Flow Doppler Ultrasonography of the Superior Thyroid Artery in the Surgical Management of Graves Disease—Invited Critique

Hypothesis: The factors affecting blood flow within the hypervascular thyroid gland and the effect of vascularization on the preparation for thyroidectomy as treatment for Graves disease can be documented. Design: Blood flow through the superior thyroid arteries of patients with Graves disease, maintained in a euthyroid status, was measured by color flow Doppler ultrasonography. The microvessel density was assessed immunohistochemically using the level of expression of factor VIII in tissue sections. Both the thyroid gland's weight and blood loss volume were measured during the operation. Setting: Tertiary care teaching hospital. Patients: Fifty-two patients with Graves disease undergoing thyroidectomy. Results: The blood flow rate was significantly correlated with thyroid weight (P<.01), thyroid microvessel density (P<.001), and histopathologic microscopic pattern (P<.001). The relation between these factors could be expressed as follows: Blood flow (mL/min) = {[0.0158+0.00136] X (weight (g) X microvessel density)} 1/2 (R 2 =0.64, P<.001). Diffuse microfollicular hyperplastic thyroid tissue had a significantly higher blood flow and vascular density than tissue having an inactive colloid pattern (P<.01). Ten patients having a blood loss exceeding 200 mL during thyroidectomy showed a higher preoperative blood flow rate and microvessel density (P<.01). Of 8 patients whose blood flow was more than 0.15 Umin, 6 (75%) had blood loss in excess of 200 mL during surgery. Conclusions: The blood flow of the superior thyroid artery is positively related to intrathyroid microvessel density, glandular weight, and histopathologic microscopic pattern. Preoperative color flow Doppler ultrasonography may help in identifying patients with Graves disease who are liable to bleed intraoperatively during thyroidectomy.

The value of color flow Doppler ultrasonography of the superior thyroid artery in the surgical management of Graves disease.

The factors affecting blood flow within the hypervascular thyroid gland and the effect of vascularization on the preparation for thyroidectomy as treatment for Graves disease can be documented. Blood flow through the superior thyroid arteries of patients with Graves disease, maintained in a euthyroid status, was measured by color flow Doppler ultrasonography. The microvessel density was assessed immunohistochemically using the level of expression of factor VIII in tissue sections. Both the thyroid gland's weight and blood loss volume were measured during the operation. Tertiary care teaching hospital. Fifty-two patients with Graves disease undergoing thyroidectomy. The blood flow rate was significantly correlated with thyroid weight (P<.01), thyroid microvessel density (P<.001), and histopathologic microscopic pattern (P<.001). The relation between these factors could be expressed as follows: Blood flow (mL/min) = [[0.0158 + 0.00136] x (weight (g) x microvessel density)](1/2) (R2 = 0.64, P<.001). Diffuse microfollicular hyperplastic thyroid tissue had a significantly higher blood flow and vascular density than tissue having an inactive colloid pattern (P<.01). Ten patients having a blood loss exceeding 200 mL during thyroidectomy showed a higher preoperative blood flow rate and microvessel density (P<.01). Of 8 patients whose blood flow was more than 0.15 L/min, 6 (75%) had blood loss in excess of 200 mL during surgery. The blood flow of the superior thyroid artery is positively related to intrathyroid microvessel density, glandular weight, and histopathologic microscopic pattern. Preoperative color flow Doppler ultrasonography may help in identifying patients with Graves disease who are liable to bleed intraoperatively during thyroidectomy.

The Use of a Selective Beta-Adrenergic Receptor Blocker for the Preoperative Preparation of Thyrotoxic Patients

Metoprolol, a cardioselective beta-blocker, was used in two asthmatic, thyrotoxic patients in preparation for thyroidectomy. Adequate reduction in resting heart rate was achieved in both individuals without inducing clinically significant airway obstruction. Beta-1-blockade can be selectively employed in this clinical setting, but patients should be hospitalized and closely monitored for adverse effects on pulmonary function. Metoprolol therapy in patients with reversible airway obstruction is discussed with reference to recent studies on relative cardioselectivity.

Thyrotoxicosis and pregnancy: Use of preoperative propranolol for thyroidectomy

Propranolol has been utilized safely and successfully in the preparation for thyroidectomy in four pregnant patients with thyrotoxicosis. No ill effects were noted in mothers or infants. No change in fetal heart function was noted while two mothers were receiving propranolol. The major advantage of propranolol over the thiourea drugs is the rapidity with which the patient can be prepared for operation. Preparation with beta blockage can be accomplished in five to ten days. This limited experience suggests that propranolol is probably the drug of choice for preparation of the gravid thyrotoxic patient for whom thyroidectomy is planned.

HYPOPROTHROMBINEMIA AS A COMPLICATION OF PROPYLTHIOURACIL.

PROPYLTHIOURACIL is of recognized value in the therapy of hyperthyroidism and the various adverse reactions to it have been thoroughly reviewed. Leukopenia and agranulocytosis are the most prominent hematologic reactions. In addition, purpura has been described. Severe hypoprothrombinemia and resultant bleeding is a rare complication of propylthiouracil, only six cases having been reported. Deficiency of several coagulation factors have been incriminated as the underlying mechanism. The patient to be presented represents an additional example of this phenomenon. <h3>Report of a Case</h3> The diagnosis of diffuse toxic goiter was made on a 27-year-old white housewife in January, 1964. The 24-hour uptake of radioactive iodine (I¹³¹) was 84%. A radioscan of the thyroid revealed diffuse, non-nodular enlargement. As preparation for thyroidectomy, propylthiouracil was administered in dosage of 100 mg every eight hours for 13 days. This was followed by a dosage of 100 mg every six hours for 17 days and

Propylthiouracil-induced agranulocytosis, toxic hepatitis, and death.

Because of its therapeutic effect and minimal toxicity, propylthiouracil has become the drug of choice in the treatment of hyperthyroidism. Leukopenia developed in only 10 of 672 patients who received the drug in preparation for thyroidectomy.1Recently, however, administration of propylthiouracil has been reported to cause death or severe disability in a few cases. Livingston and Livingston2reported a nonfatal case of toxic hepatitis following treatment with the drug. Two other fatalities from agranulocytosis have been described previously in the literature.3This is a report of a third death due to agranulocytosis, associated with early toxic hepatitis, following the administration of propylthiouracil. REPORT OF CASE History.— A white woman, a secretary, aged 60, was admitted to Evanston Hospital on Aug. 17, 1950. Until two weeks before admission she had been perfectly well. At that time she noticed palpitation and a tightness in the chest on reclining

The Action of Thiouracil upon the Thyroid Gland in Graves' Disease1

THE demonstration by the Mackenzies (1) and by Astwood and his collaborators (2, 3) that thiourea and related compounds affect the thyroid gland in a striking and peculiar manner placed in the hands of thyroidologists both a new tool for studying thyroid physiology and a therapeutic agent of interesting potentialities. Prior to the reports of the investigators just mentioned, our interest in goitrogenous agents had been aroused by the finding of patients made goiterous by the use of thiocyanate for the treatment of hypertension (4). When the thioureas appeared on the scene, therefore, we decided at once to obtain personal experience in the use of such an agent in cases of Graves' disease. We selected thiouracil, the member of this group advocated by Astwood (5) as most suitable for this purpose. Three questions particularly interested us. First, what is the action of thiouracil upon the thyroid gland in Graves' disease? Second, what is its value as a preparation for thyroidectomy in Graves' disease? And t...