Management of Complications

1. Airway Obstruction

Although respiratory problems in the postoperative period are relatively uncommon they can be life threatening and diagnosis and treatment must be prompt.

UPPER AIRWAY OBSTRUCTION

This may be subtle at its onset. Look for symptoms of hypoxia such as restlessness, irritability and SOB.

Partial Obstruction

This may be indicated by:

 

1. Inspiratory stridor

2. Laboured breathing: use of the accessory muscles of respiration (sternomastoids, scalenes) with retraction of the head on inspiration and flaring of nostrils.

3. Rocking movements of the abdomen and chest.

Complete Obstruction

This may be indicated by:

 

  1. No movement of air is detectable at the airway.

  2. No breath sounds.

  3. Signs of hypoxia rapidly developed.

  4. Dysrhythmias and bradycardia.

CAUSES
  1. Tongue: In the unconscious patient with the jaw relaxed the tongue may fall back and obstruct airway.

  2. Foreign materials in the pharynx:

    A. Mucous or saliva

    B. Gastric contents from vomiting and regurgitation

    C. Blood following oral and nasal surgery (also in the case of  thyroidectomy)

  3. Laryngospasm: Dyspnoea and wheeze particularly in expiration.

  4. Laryngeal oedema: Oedema in the neck is edema of larynx and glottis. This is  the most common cause of postoperative respiratory distress. This may be due to dissection and manipulation around thyroid and cricoid cartilage and the hypopharyngeal muscles. Also it may follow post intubation.

  5. Haematoma causing external pressure on the trachea.

  6. RLN palsy.

  7. Tracheal collapse (tracheomalacia) following thyroidectomy. 

TREATMENT
  1. Nurse completely upright (90°).

  2. Supplemental high flow oxygen

  3. Continuous Sat O2 monitoring.

  4. Call for senior help immediately

    A. Senior anaesthetist.

    B. Surgeon (myself).

    C. ICU.

    D. Theatre co-coordinator.

    E. Nurse Manager.

  5. Early re-intubation.

    A. ET intubation should ONLY be performed by experienced anaesthetist.

    B. Decompressing wound may facilitate intubation.

  6. Consider removing skin AND strap muscle sutures until trachea seen.

    A. In most cases this will be performed in theatre if patient not distressed.

    B. Respiratory distress or respiratory arrest are indications for IMMEDIATE wound opening.

    C. Blood transfusion is never necessary.

  7. Consider hydrocortisone 100mg stat.

2. Calcium imbalanace

CLINICAL FEATURES OF HYPOCALCAEMIA

Early

 

1. Peripheral paraesthesia.

2. Circumoral paraesthesia.

3. Chvostek’s sign:

     * tapping over facial nerve trunk elicits facial muscle spasms.

     * seen in 10% normal population therefore should be checked before operation.

 

Late

 

1. Trousseau’s sign:

     * occluding brachial artery for 2 minutes induces carpal spasm.

2. Carpopedal spasm.

3. Neuromuscular irritability.

     * muscle cramps.

     * muscle spasms.

     * tetany or seizure.

4. Laryngeal stridor.

5. Cardiac arrhythmia.

     * prolonged Q-T interval.

     * hypotension.

     * VF or heart block.

NATURAL HISTORY

Asymptomatic hypocalcaemia

     * within 12 hours following surgery is common.

     * recovers spontaneously within 24 hours in most patients.

 

Transient hypocalcaemia

     * serum total calcium (Ca total++)         < 2.0 mmol/L**.

     * serum ionized calcium (Ca i++)           < 1.0 mmol/L**.

 

     ** for 2 consecutive days +/- symptoms or signs of hypocalcaemia.

 

Permanent hypoparathyroidism

     * requirement for calcium supplementation or vitamin D (or both) to maintain eucalcaemia 1 year after thyroidectomy.

MANAGEMENT
Who is at risk of hypocalcaemia?
Blood tests:

All patient who have Total Thyroidectomy but espcially:

  • Thyroid cancer with lymphadenectomy

  • Graves' disease

  • Very large goitres

 

Parathyroid patients who have risk of hungry bone syndrome:

  • Secondary hyperparathyroidism

  • Large primary parathyroid tumours

  • Patients with high bone turnover markers

 

NOTE: All patients having total thyroidectomy are given calcium replacement which in most cases will be stopped after 2 weeks.

 

URGENT PTH and Calcium once patient arrives on ward from theatre: approx. 4 hrs post-op (remember to write URGENT on the request form).

           

PTH in normal range and Corrected Calcium in normal range

  • Caltrate 2 tab bd; Calcitriol 1 tab bd; Discharge mane if no other problems

  • 2 weeks supply only

 

 

PTH low or unrecordable and Corrected Calcium > 2 mmol/L and no Symptoms

  • Caltrate 2 tab tds; Calcitriol 1 tab tds; Discharge mane with pt given request for PTH/Ca prior to OPD appointment.

  • CalSource prn if symptomatic at home: 1 tablet to be taken hourly until symptoms settle (in addition to Caltrate and Calcitriol)

 

PTH low or unrecordable and Corrected Calcium < 2 mmol/L or Symptoms

  • Caltrate 2 tabs tds; Calcitriol 2 tab tds; Keep in extra day and recheck Calcium mane; If positive trend Ca home with request for PTH/Ca prior to OPD appointment

  • CalSource prn if symptomatic at home: 1 tablet to be taken hourly until symptoms settle (in addition to Caltrate and Calcitriol)

  • Do not discharge until Calcium > 2 mmol/L

 

NOTE: Before discharge ensure Corrected Calcium > 2.0 mmol/L

Calcium Replacement Dosing:

NOTE: Replace calcium ONLY after serum taken for calcium estimation

 

Calcium

      

ALL

 

  • Encourage Ca containing food (dairy, canned fish)

 

>2.0 mmol/L

 

  • Caltrate 600mg 2 tab bd AND

  • Calcitriol 0.25 mcg bd AND

  • Calsource 1 tablet hourly until asymptomatic

 

1.6-2.0 mmol/L 

     

  • Caltrate 600mg 2 tab tds AND

  • Calcitriol 0.25mcg 2 tab tds

  • Calsource 1 tablet hourly until asymptomatic

 

<1.6 mmol/L

                                

  • Notify Surgeon (Endocrine Surgery Fellow or Mr Lisewski).

 

  • 10% Calcium Gluconate IVI

    • Loading: 10ml over 10 min.

    • Can be given through peripheral vein (syringe driver)

    • Maintenance: 60-120ml in 1L NS over 24 hr 

    • Must be given through central vein

  • Magnesium sulphate 25-50 mmol IVI over 24 hrs.

    •  Correct if Mg++ < 0.5 mmol/L.

 

NOTE: extravastation will lead to extensive tissue necrosis. Make certain cannula is not tissued. Never use foot vein.

3. Voice Change

LARYNGEAL OEDEMA

Oedema affecting the intrinsic larynx is the most common cause of post thyroidectomy hoarseness. Direct effects of manipulation of the cricopharyngeal muscle and the cricoid and thyroid cartilages perhaps of interruption of the lymphatics in the area account for most of the edema. Also dissection around the larynx may repeatedly press and rub the vocal cords onto the relatively hard, immobile endotracheal tube. A mild degree of edema produces a roughened somewhat harsh voice but as edema progresses and the cords because more involved voice volume may diminish.

LARYNGEAL NERVE INJURY
Recurrent Laryngeal Nerve

Incidence:

 

  • 0.5-1% permanent 

  • 3-4% transient

 

Function:

 

  • Motor: all intrinsic muscles of the larynx except cricothyoid.

  • Sensory: subglottic sensation

 

Deficit:

 

Vocal cord is adducted towards midline in a paramedian position.

 

  • Single nerve injury:   

    • Weak, hoarse voice.

    • Dyspnoea on exertion.

    • Bovine cough

 

  • Bilateral nerve injury:

    • Aphonia or weak, whispery voice.

    • Aspiration of fluids.

    • Stridor soon after operation, severe dyspnoea.

 

Management:

 

  • Reassure as most vocal change is transient

  • Use voice to strengthen it (read aloud, sing, talk more than usual)

  • Nasendoscopy will be arranged at the 2 weeks post-op visit.

  • Speech therapy will help.

  • 3 monthly nasendoscopy until resolved.

  • If paresis persists beyon 12 month than it is permanent and ENT referral will be arranged.

© 2016 PTCC. Proudly created with Wix.com.

  • Wix Facebook page
  • Twitter Classic
  • Google Classic