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de Mul N, Damstra J, Nieveen van Dijkum EJM, Fischli S, Kalkman CJ, Schellekens WJM, Immink RV. The risk of perioperative thyroid storm in hyperthyroid patients: a systematic review. Br J Anaesth 2021; 127:879-889. [PMID: 34389171 DOI: 10.1016/j.bja.2021.06.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/07/2021] [Accepted: 06/25/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Thyroid storm is a feared complication in patients with hyperthyroidism undergoing surgery. We assessed the risk of thyroid storm for different preoperative treatment options for patients with primary hyperthyroidism undergoing surgery. METHODS Pubmed, EMBASE, and The Cochrane Library were searched systematically for all studies reporting on adult hyperthyroid patients undergoing elective surgery under general anaesthesia. Selected studies were categorised based on preoperative treatment: no treatment, antithyroid medication (thionamides), iodine, β-blocking medication, or a combination thereof. Treatment effect, that is restoring euthyroidism, was extracted from the publications if available. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) or the Cochrane Risk of Bias tool for randomised studies. RESULTS The search yielded 7009 articles, of which 26 studies published between 1975 and 2020 were selected for critical appraisal. All studies had moderate to critical risk of bias, mainly attributable to risk of confounding, classification of intervention status, and definition of the outcome. All studies reported on thyroidectomy patients. We found no randomised studies comparing the risk of thyroid storm between treated and untreated patients. Cases of thyroid storm were reported in all treatment groups with incidences described ranging from 0% to 14%. CONCLUSION Evidence assessing the risk of perioperative thyroid storm is of insufficient quality. Given the seriousness of this complication and the impossibility of identifying patients at increased risk, preoperative treatment of these patients remains warranted.
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Affiliation(s)
- Nikki de Mul
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jill Damstra
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Els J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; European Society of Endocrine Surgeons
| | - Stefan Fischli
- Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Cor J Kalkman
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem-Jan M Schellekens
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Rogier V Immink
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Smithson M, Asban A, Miller J, Chen H. Considerations for Thyroidectomy as Treatment for Graves Disease. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2019; 12:1179551419844523. [PMID: 31040734 PMCID: PMC6482648 DOI: 10.1177/1179551419844523] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
Hyperthyroidism is a clinical state that results from abnormally elevated thyroid hormones. Thyroid gland affects many organ systems; therefore, patients usually present with multiple clinical manifestations that involve many organ systems such as the nervous, cardiovascular, muscular, and endocrine system as well as skin manifestations. Hyperthyroidism is most commonly caused by Graves disease, which is caused by autoantibodies to the thyrotropin receptor (TRAb). Other causes of hyperthyroidism include toxic multinodular goiter, toxic single adenoma, and thyroiditis. Diagnosis of hyperthyroidism can be established by measurement of thyroid-stimulating hormone (TSH), which will be suppressed with either elevated free T4 and/or T3 (overt hyperthyroidism) or normal free T3 and T4 (subclinical hyperthyroidism). Hyperthyroidism can be treated with antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy. ATDs have a higher replacement rate when compared with RAI or thyroidectomy. Recent evidence has shown that thyroidectomy is a very effective, safe treatment modality for hyperthyroidism and can be performed as an outpatient procedure. This review article provides some of the most recent evidence on diagnosing and treating patients with hyperthyroidism.
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Affiliation(s)
- Mary Smithson
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar Asban
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason Miller
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
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Calissendorff J, Falhammar H. Rescue pre-operative treatment with Lugol's solution in uncontrolled Graves' disease. Endocr Connect 2017; 6:200-205. [PMID: 28325735 PMCID: PMC5434745 DOI: 10.1530/ec-17-0025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/21/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Graves' disease is a common cause of hyperthyroidism. Three therapies have been used for decades: pharmacologic therapy, surgery and radioiodine. In case of adverse events, especially agranulocytosis or hepatotoxicity, pre-treatment with Lugol's solution containing iodine/potassium iodide to induce euthyroidism before surgery could be advocated, but this has rarely been reported. METHODS All patients hospitalised due to uncontrolled hyperthyroidism at the Karolinska University Hospital 2005-2015 and treated with Lugol's solution were included. All electronic files were carefully reviewed manually, with focus on the cause of treatment and admission, demographic data, and effects of iodine on thyroid hormone levels and pulse frequency. RESULTS Twenty-seven patients were included. Lugol's solution had been chosen due to agranulocytosis in 9 (33%), hepatotoxicity in 2 (7%), other side effects in 11 (41%) and poor adherence to medication in 5 (19%). Levels of free T4, free T3 and heart rate decreased significantly after 5-9 days of iodine therapy (free T4 53-20 pmol/L, P = 0.0002; free T3 20-6.5 pmol/L, P = 0.04; heart rate 87-76 beats/min P = 0.0007), whereas TSH remained unchanged. Side effects were noted in 4 (15%) (rash n = 2, rash and vomiting n = 1, swelling of fingers n = 1). Thyroidectomy was performed in 26 patients (96%) and one was treated with radioiodine; all treatments were without serious complications. CONCLUSION Treatment of uncontrolled hyperthyroidism with Lugol's solution before definitive treatment is safe and it decreases thyroid hormone levels and heart rate. Side effects were limited. Lugol's solution could be recommended pre-operatively in Graves' disease with failed medical treatment, especially if side effects to anti-thyroid drugs have occurred.
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Affiliation(s)
- Jan Calissendorff
- Department of EndocrinologyMetabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of EndocrinologyMetabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
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Palace MR. Perioperative Management of Thyroid Dysfunction. Health Serv Insights 2017; 10:1178632916689677. [PMID: 28469454 PMCID: PMC5398303 DOI: 10.1177/1178632916689677] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/19/2016] [Indexed: 12/02/2022] Open
Abstract
Due to the manifold effects of thyroid hormone across virtually all organ systems, the complications associated with thyroid dysfunction are numerous and diverse. The stresses encountered during the perioperative period may exacerbate underlying thyroid disorders, potentially precipitating decompensation and even death. Thus, it is of the utmost importance for the clinician to comprehend the mechanisms by which thyroid disease may complicate surgery and postoperative recovery and to be cognizant of the most effective means of optimizing the status of thyrotoxic and hypothyroid patients perioperatively. This article describes the adverse effects of thyroid dysfunction as they relate to the patient undergoing both thyroid and nonthyroid surgery and recommends treatment approaches aimed at decreasing perioperative risk.
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Affiliation(s)
- Marcia Rashelle Palace
- Division of Endocrinology, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
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Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev 2012; 33:920-80. [PMID: 22961916 DOI: 10.1210/er.2012-1030] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
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Sequential defunctionalization followed by thyroxine supplementation as preoperative preparation of hyperthyroid patients undergoing thyroidectomy. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200810020-00012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Preoperative thyrotoxicosis is a potentially life-threatening condition that requires medical intervention before surgery. Most patients are undergoing thyroidectomy for persistent thyrotoxicosis, usually Graves' disease, either having contraindications to or failing medical therapy. Fewer patients are undergoing nonthyroidal surgery that is likely urgent or emergent. The choice of treatment depends on the time available for preoperative preparation, the severity of the thyrotoxicosis, and the impact of any current or previous therapies. Generally treatment is directed at a combination of targets in the thyroid hormone synthetic, secretory, and peripheral pathway with concurrent treatment to correct any decompensation of normal homeostatic mechanisms. Thionamides are the preferred initial treatment unless contraindicated, but do require several weeks to render a patient euthyroid. beta-Blockers should always be used unless absolutely contraindicated because they improve thyrotoxic symptoms especially of the cardiovascular system. Other agents including iodine and steroids can be used if rapid preparation is required or more severe thyrotoxicosis is present. The goal of therapy is to render the patient as close as possible to clinical and biochemical euthyroidism before surgery. Overall, the morbidity and mortality of adequately prepared patients is low.
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Affiliation(s)
- Roy W Langley
- Endocrine-Metabolic Service, Department of Medicine, Walter Reed Army Medical Center, Washington, DC 20307, USA
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Jansson S, Lie-Karlsen K, Stenqvist O, Körner U, Lundholm K, Tisell LE. Oxygen consumption in patients with hyperthyroidism before and after treatment with beta-blockade versus thyrostatic treatment: a prospective randomized study. Ann Surg 2001; 233:60-4. [PMID: 11141226 PMCID: PMC1421167 DOI: 10.1097/00000658-200101000-00010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate randomly the effect of thyrostatic treatment (tiamazole) versus selective (metoprolol) and nonselective beta-blockade (propranolol) on whole-body energy metabolism in women with hyperthyroidism. SUMMARY BACKGROUND DATA beta-blockade is used as an alternative to thyrostatic drugs in the preoperative treatment of patients with hyperthyroidism. beta-blockers have well-established symptomatic effects, but in contrast to antithyroid drugs beta-blockade is thought to lack direct effects on the increased metabolism in hyperthyroidism. METHODS Whole-body oxygen consumption and carbon dioxide production was measured in a semiopen canopy system with paramagnetic O2 and infrared CO2 sensors. A constant flow generator and the gas-dilution method for calculation of gas flow were used. Anabolic parameters were body weight, triceps skinfold, and arm muscle circumference. RESULTS Tiamazole normalized oxygen consumption and induced signs of anabolism with improved nutritional state. Metroprolol did not affect oxygen consumption. Propranolol reduced elevated oxygen consumption by 54%. Body weight and other anthropometric assessments were stable after specific and nonspecific beta-blockade, which also led to symptomatic relief in approximately 90% of the patients. CONCLUSION Tiamazole was the most effective drug to oppose the adverse effects of hyperthyroidism. Therefore, thyrostatic agents are recommended for preoperative treatments of patients with severe catabolic hyperthyroidism. Whenever beta-blockers are chosen for treatment of hyperthyroidism, propranolol (beta 1 + beta 2) has an advantage because it reduces the metabolic rate, whereas selective beta 1-blockade seemed to provide only symptomatic relief, related to the normalization of heart rate.
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Affiliation(s)
- S Jansson
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden.
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Foster DJ, Thoday KL. Use of propranolol and potassium iodate in the presurgical management of hyperthyroid cats. J Small Anim Pract 1999; 40:307-15. [PMID: 10444749 DOI: 10.1111/j.1748-5827.1999.tb03087.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A prospective study was carried out using a combination of propranolol and potassium iodate to assess whether there were beneficial effects in preparing hyperthyroid cats for surgical thyroidectomy. Group A (n = 11) received propranolol from days 1 to 10, followed by propranolol and potassium iodate from days 11 to 20; group B (n = 10) received the reverse regimen. Blood samples were taken daily for subsequent determination of serum total L-thyroxine (TT4), L-triiodothyronine (TT3) and reverse T3 (rT3) concentrations. The signs of hyperthyroidism improved in all cats over the treatment period. At surgery, 36 per cent of the cats in group A had reference range serum TT4 concentrations, while 89 per cent with initially elevated TT3 concentrations had reference range concentrations. In group B, 10 per cent of the cats had reference range TT4 concentrations, while 75 per cent with initially elevated TT3 concentrations had reference range concentrations. The drug regimen used in group A was better tolerated and more effective and offers an alternative before thyroidectomy in cats that cannot tolerate carbimazole.
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Affiliation(s)
- D J Foster
- Department of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Veterinary Centre, Roslin, Midlothian
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Royal academy of medicine in Ireland section of anaesthesia. Ir J Med Sci 1990. [DOI: 10.1007/bf02937382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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