What is the management of postoperative hyperthyroidism?

Management of Postoperative Hyperthyroidism

In cases of suspected postoperative hyperthyroidism following thyroid surgery, immediate management should begin with supplemental oxygen administration, head-up positioning, and urgent senior surgical or anesthetic review, followed by the SCOOP approach (Skin exposure, Cut sutures, Open skin, Open muscles, Pack wound) if airway compromise is present. 1

Immediate Recognition and Assessment

Signs and Symptoms to Monitor

• Arterial oxygen desaturation
• Difficulty breathing
• Stridor (may be a late sign)
• Tachypnea
• Rapidly expanding neck swelling
• Agitation, anxiety, discomfort

Initial Management Steps

1. Administer supplemental oxygen immediately 1
2. Position patient in head-up position 1
3. Evaluate airway patency concurrently with management 1
4. Call for help if signs of airway compromise are present 1

Management Algorithm

If Airway Compromise is Present:

1. Immediate senior anesthetist notification 1
2. Proceed to haematoma evacuation using SCOOP approach: 1
   • Skin exposure
   • Cut sutures
   • Open skin
   • Open muscles (both superficial and deep layers)
   • Pack wound
3. No local anesthetic infiltration is required 1
4. If evacuation fails to stabilize patient, consider emergency tracheal intubation 1

If No Immediate Airway Compromise:

1. Arrange immediate senior surgical review (registrar or consultant) 1
2. If senior surgical review unavailable, arrange senior anesthetic review 1
3. Consider flexible endoscopic laryngeal assessment 1
4. Consider intravenous dexamethasone and tranexamic acid 1
5. Increase frequency of observations 1
6. Consider transfer to operating theater, PACU, or ICU if ongoing concerns 1

Equipment and Preparation

Post-Thyroid Surgery Emergency Box

• Must be available at bedside of all patients who have undergone thyroid surgery 1
• Should accompany patients during transfers 1
• Contains essential equipment for opening neck wound in case of haematoma 1

Monitoring Requirements

• Wound inspection
• Early warning scoring
• Pain scoring
• Awareness of subtle signs (agitation, anxiety, breathing difficulty, discomfort) 1
• Hourly observations for first 6 hours postoperatively 1
• After 6 hours, frequency may be tailored to individual risk 1

Preventive Measures and Staff Preparation

• All staff interacting with thyroid surgery patients should be trained to recognize haematoma 1
• Emergency front-of-neck airway equipment must be readily available on wards caring for post-thyroid surgery patients 1
• Organizations should support multidisciplinary team training for managing complications 1

Important Considerations

• Postoperative haemorrhage is a well-recognized complication of thyroid surgery (0.45-4.2% incidence) 1
• Rapid haematoma formation, even with small volumes, can cause significant airway obstruction 1
• Stridor may be a late sign and warrants immediate management 1
• Local anesthetic infiltration is not required when opening the wound 1
• After emergency haematoma evacuation, surgical team should communicate with patient and offer psychological support 1

By following this systematic approach to managing postoperative hyperthyroidism complications, healthcare providers can minimize morbidity and mortality associated with this potentially life-threatening condition.