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Preparation of the Thyroid Patient for Operation
Preparation of the Thyroid Patient for Operation HENRY.H. SEARLS, M.D., F.A.C.S.*
INDICATIONS
INDICATIONS for surgical treatment may be found in patients with various types of goiter. Toxic effects mayor may not be demonstrable. Nontoxic goiter may be treated surgically if it is nodular or if it exhibits evidence of chronic inflammation. Toxic goiter may be nodular or diffuse; if nodular, surgical treatment is positively indicated; if diffuse, subtotal thyroidectomy is one of several recognized methods of therapy. Preoperative preparation varies in these different types of goiter. NONTOXIC NODULAR GOITER
The patient with a nontoxic nodular goiter who is otherwise in a normal state of health requires no special preparation for operation. A thorough investigation of the patient's condition must be made, however, including: 1. Fluoroscopic examination of the neck and chest to establish the presence or absence of retrotracheal or intrathoracic goiter; 2. An evaluation of cardiac capacity, including an electrocardiogram; 3. Indirect laryngoscopy to determine vocal cord function. In the preoperative treatment of nontoxic nodular goiter, bed rest and prolonged premedication are not required. The patient may enter the hospital on the day before the scheduled operation. Routine preoperative orders might be written as follows: 1. Nothing by mouth after midnight. 2. Tap-water enema in the evening. 3. Pentobarbital sodium 0.1 gram at the hour of sleep and at 6:30 the following morning. 4. Neck, shoulders and upper chest to be scrubbed with soap and From the Department of Surgery, University of California Medical School, San Francisco.
* Associate Professor of Surgery, University of California Medical School; Surgeonin-Charge, Surgical Outpatient Department, and Visiting Surgeon, University of California Hospital, University of California Medical Center. 1359
Henry H. Searls
1360
water in preparation for operation; the male patient must shave carefully. 5. Morphine sulfate 10 mg. and scopolamine 0.4 mg. by hypodermic when called to the operating room. TOXIC GOITER
Currently, three methods of treatment offer relief to the patient with toxic goiter; namely, antithyroid drugs, radioactive iodine, and surgery. We strongly urge that nonsurgical therapy be limited to the relief of carefully selected patients exhibiting the clinical picture of toxic diffuse goiter (Graves' disease). Toxic Nodular Goiter remains a surgical disease. Unless complications have developed, the average patient exhibiting this condition requires little preoperative preparation other than that suggested for the nontoxic patient. In such patients, the hyperthyroidism itself is usually mild and the delay involved in its reduction by antithyroid drugs is not warranted. However, it is the neglected patient with toxic nodular goiter who most often presents evidence of marked myocardial damage and the associated picture of cardiac decompensation. A common manifestation of this type of toxic myocarditis is auricular fibrillation. Its persistence after intensive therapy usually is not a contraindication to thyroidectomy. In the preoperative preparation of such a patient, antithyroid drugs such as propylthiouracil (400 to 600 mg.) or Tapazole (20 to 40 mg.) should be administered daily. At the same time, bed rest and digitalis or quinidine should be ordered, preferably under the supervision of a consultant internist. A salt-free or low salt diet may aid in ridding the patient of excess fluid. When adequate restoration of the cardiovascular system has been accomplished, iodine in the form of Lugol's solution (10 drops three times daily) should be substituted for the antithyroid drug during the 10 days immediately preceding operation. Toxic Diffuse Goiter. Although the patient with toxic diffuse goiter (Graves' disease) may respond to medical measures, proper subtotal thyroidectomy after adequate preparation remains a rational procedure and offers the advantage of rapid and permanent relief. Preoperative preparation of this type of patient requires a considerable time interval. It includes diet, sedation, rest, and the administration of antithyroid drugs. Excessive metabolic demands in hyperthyroidism may result in energy requirements of 6000 to 8000 calories daily. The associated voracious appetite aids in accomplishing high intake. Multiple meals (4 to 6) should be planned. The diet should be balanced and palatable. It should include 1 to 2 grams of protein per kilogram of body weight. Fats offer a high concentration of calories and thereby cut down the bulk of food required.
Preparation of Thyroid Patient for Operation
1361
The higher grade fats, such as butter and cream, offer better protection to the liver. They should provide one-third of the daily caloric intake. Carbohydrates are valuable in this disease, as they offer rapid conversion to energy. In the form of cereals, bread, potatoes and sugars, they should have a prominent place in the diet. Many fruits have a high sugar content. Milk sugar may be added to fruits, fruit juices, and cereals. There is an increased demand for vitamins, especially A, B, C and D. Increased excretion of calcium may require its addition to the diet. A high fluid intake should be maintained. Tea, coffee, tobacco and alcohol must be avoided. The patient with toxic diffuse goiter usually exhibits extreme nervousness, tremor, and emotionalism. Fairly heavy and frequent sedation is effective in controlling this phase of the disease. Phenobarbital, 30 mg., taken three to four times daily, should prove adequate. Complete bed rest may be essential for the patient with extreme toxicity. Certainly the young patient should be withdrawn from school. When possible the housewife should be relieved of her duties. Sick leave is essential for the employed patient. For the patient with moderately severe symptoms, the regimen should include long periods of nocturnal bed rest, together with an additional hour or two in the afternoon. In 1923, Plummer reported that the administration of iodine in the form of Lugol's solution to patients with Graves' disease resulted in a dramatic temporary relief of toxic symptoms. He recommended its use in preparation for thyroidectomy. Acceptance of this plan (0.6 cc. or 10 drops of Lugol's solution three times a day for 10 to 20 days before operation) resulted in a sharp drop in both postoperative reactions and mortality rates in the surgical treatment of toxic goiter. Iodine has remained in a position of primary importance in the preoperative preparation of patients with toxic diffuse goiter and, to a lesser degree, of those with toxic nodular goiter. Iodization of the gland not only reduces toxic symptoms and postoperative reactions, but also, by decreasing the vascularity and toughening the glandular tissue, materially facilitates subtotal thyroidectomy. The so-called antithyroid drugs in use at the present time include propylthiouracil and 1-methyl-2-mercapto-imidazole (Tapazole). Often used in the prolonged medical treatment of patients with toxic goiter, these drugs are also of value in preparation for thyroidectomy. The character of the patient's response to these drugs determines the direction of definitive care. If improvement is immediate and dramatic, continuing antithyroid drug therapy together with other medical measures previously outlined promises hope of permanent relief. If reduction of toxicity proves to be slow and the syndrome resistant to antithyroid therapy, or if toxicity redevelops after cessation of this plan of treatment, subtotal thyroidectomy will cure the patient. The daily dosage of propylthiouracil should range from 400 to 600
1362
Henry H. Searls
mg., that of Tapazole from 20 to 50 mg. When initiating such a regimen, the patient should be informed of the possible failure of medical treatment and of the alternative of definitive relief by operation. Inadequate response to such a medical plan is an indication for operation. At this point, replacement of propylthiouracil or Tapazole by Lugol's solution is the final step in preparation for operation. Reduction of vascularity, disappearance of the bruit over the gland, and increailed firmness of glandular tissue in association with weight gain and a reduction in the pulse rate below 90 per minute indicate a readiness for thyroidectomy. The immediate preoperative preparation is similar to that suggested for the nontoxic case, except for increased sedation. Preoperative enema may upset the toxic patient and should be excluded. Preoperative orders for this type of patient may be written as follows: 1. Nothing by mouth after midnight. 2. No enema. 3. Pentobarbital sodium 10 mg. at the hour of sleep and repeated in 4 hours if patient is awake. 4. Pentobarbital sodium 10 mg. at 6:30 A.M. 5. Morphine sulfate 15 mg. and atropine 0.6 mg. at call to the operating room. University of California Hospital San Francisco 22, California
INDICATIONS
INDICATIONS for surgical treatment may be found in patients with various types of goiter. Toxic effects mayor may not be demonstrable. Nontoxic goiter may be treated surgically if it is nodular or if it exhibits evidence of chronic inflammation. Toxic goiter may be nodular or diffuse; if nodular, surgical treatment is positively indicated; if diffuse, subtotal thyroidectomy is one of several recognized methods of therapy. Preoperative preparation varies in these different types of goiter. NONTOXIC NODULAR GOITER
The patient with a nontoxic nodular goiter who is otherwise in a normal state of health requires no special preparation for operation. A thorough investigation of the patient's condition must be made, however, including: 1. Fluoroscopic examination of the neck and chest to establish the presence or absence of retrotracheal or intrathoracic goiter; 2. An evaluation of cardiac capacity, including an electrocardiogram; 3. Indirect laryngoscopy to determine vocal cord function. In the preoperative treatment of nontoxic nodular goiter, bed rest and prolonged premedication are not required. The patient may enter the hospital on the day before the scheduled operation. Routine preoperative orders might be written as follows: 1. Nothing by mouth after midnight. 2. Tap-water enema in the evening. 3. Pentobarbital sodium 0.1 gram at the hour of sleep and at 6:30 the following morning. 4. Neck, shoulders and upper chest to be scrubbed with soap and From the Department of Surgery, University of California Medical School, San Francisco.
* Associate Professor of Surgery, University of California Medical School; Surgeonin-Charge, Surgical Outpatient Department, and Visiting Surgeon, University of California Hospital, University of California Medical Center. 1359
Henry H. Searls
1360
water in preparation for operation; the male patient must shave carefully. 5. Morphine sulfate 10 mg. and scopolamine 0.4 mg. by hypodermic when called to the operating room. TOXIC GOITER
Currently, three methods of treatment offer relief to the patient with toxic goiter; namely, antithyroid drugs, radioactive iodine, and surgery. We strongly urge that nonsurgical therapy be limited to the relief of carefully selected patients exhibiting the clinical picture of toxic diffuse goiter (Graves' disease). Toxic Nodular Goiter remains a surgical disease. Unless complications have developed, the average patient exhibiting this condition requires little preoperative preparation other than that suggested for the nontoxic patient. In such patients, the hyperthyroidism itself is usually mild and the delay involved in its reduction by antithyroid drugs is not warranted. However, it is the neglected patient with toxic nodular goiter who most often presents evidence of marked myocardial damage and the associated picture of cardiac decompensation. A common manifestation of this type of toxic myocarditis is auricular fibrillation. Its persistence after intensive therapy usually is not a contraindication to thyroidectomy. In the preoperative preparation of such a patient, antithyroid drugs such as propylthiouracil (400 to 600 mg.) or Tapazole (20 to 40 mg.) should be administered daily. At the same time, bed rest and digitalis or quinidine should be ordered, preferably under the supervision of a consultant internist. A salt-free or low salt diet may aid in ridding the patient of excess fluid. When adequate restoration of the cardiovascular system has been accomplished, iodine in the form of Lugol's solution (10 drops three times daily) should be substituted for the antithyroid drug during the 10 days immediately preceding operation. Toxic Diffuse Goiter. Although the patient with toxic diffuse goiter (Graves' disease) may respond to medical measures, proper subtotal thyroidectomy after adequate preparation remains a rational procedure and offers the advantage of rapid and permanent relief. Preoperative preparation of this type of patient requires a considerable time interval. It includes diet, sedation, rest, and the administration of antithyroid drugs. Excessive metabolic demands in hyperthyroidism may result in energy requirements of 6000 to 8000 calories daily. The associated voracious appetite aids in accomplishing high intake. Multiple meals (4 to 6) should be planned. The diet should be balanced and palatable. It should include 1 to 2 grams of protein per kilogram of body weight. Fats offer a high concentration of calories and thereby cut down the bulk of food required.
Preparation of Thyroid Patient for Operation
1361
The higher grade fats, such as butter and cream, offer better protection to the liver. They should provide one-third of the daily caloric intake. Carbohydrates are valuable in this disease, as they offer rapid conversion to energy. In the form of cereals, bread, potatoes and sugars, they should have a prominent place in the diet. Many fruits have a high sugar content. Milk sugar may be added to fruits, fruit juices, and cereals. There is an increased demand for vitamins, especially A, B, C and D. Increased excretion of calcium may require its addition to the diet. A high fluid intake should be maintained. Tea, coffee, tobacco and alcohol must be avoided. The patient with toxic diffuse goiter usually exhibits extreme nervousness, tremor, and emotionalism. Fairly heavy and frequent sedation is effective in controlling this phase of the disease. Phenobarbital, 30 mg., taken three to four times daily, should prove adequate. Complete bed rest may be essential for the patient with extreme toxicity. Certainly the young patient should be withdrawn from school. When possible the housewife should be relieved of her duties. Sick leave is essential for the employed patient. For the patient with moderately severe symptoms, the regimen should include long periods of nocturnal bed rest, together with an additional hour or two in the afternoon. In 1923, Plummer reported that the administration of iodine in the form of Lugol's solution to patients with Graves' disease resulted in a dramatic temporary relief of toxic symptoms. He recommended its use in preparation for thyroidectomy. Acceptance of this plan (0.6 cc. or 10 drops of Lugol's solution three times a day for 10 to 20 days before operation) resulted in a sharp drop in both postoperative reactions and mortality rates in the surgical treatment of toxic goiter. Iodine has remained in a position of primary importance in the preoperative preparation of patients with toxic diffuse goiter and, to a lesser degree, of those with toxic nodular goiter. Iodization of the gland not only reduces toxic symptoms and postoperative reactions, but also, by decreasing the vascularity and toughening the glandular tissue, materially facilitates subtotal thyroidectomy. The so-called antithyroid drugs in use at the present time include propylthiouracil and 1-methyl-2-mercapto-imidazole (Tapazole). Often used in the prolonged medical treatment of patients with toxic goiter, these drugs are also of value in preparation for thyroidectomy. The character of the patient's response to these drugs determines the direction of definitive care. If improvement is immediate and dramatic, continuing antithyroid drug therapy together with other medical measures previously outlined promises hope of permanent relief. If reduction of toxicity proves to be slow and the syndrome resistant to antithyroid therapy, or if toxicity redevelops after cessation of this plan of treatment, subtotal thyroidectomy will cure the patient. The daily dosage of propylthiouracil should range from 400 to 600
1362
Henry H. Searls
mg., that of Tapazole from 20 to 50 mg. When initiating such a regimen, the patient should be informed of the possible failure of medical treatment and of the alternative of definitive relief by operation. Inadequate response to such a medical plan is an indication for operation. At this point, replacement of propylthiouracil or Tapazole by Lugol's solution is the final step in preparation for operation. Reduction of vascularity, disappearance of the bruit over the gland, and increailed firmness of glandular tissue in association with weight gain and a reduction in the pulse rate below 90 per minute indicate a readiness for thyroidectomy. The immediate preoperative preparation is similar to that suggested for the nontoxic case, except for increased sedation. Preoperative enema may upset the toxic patient and should be excluded. Preoperative orders for this type of patient may be written as follows: 1. Nothing by mouth after midnight. 2. No enema. 3. Pentobarbital sodium 10 mg. at the hour of sleep and repeated in 4 hours if patient is awake. 4. Pentobarbital sodium 10 mg. at 6:30 A.M. 5. Morphine sulfate 15 mg. and atropine 0.6 mg. at call to the operating room. University of California Hospital San Francisco 22, California