What is the recommended anesthesia regimen for parathyroid surgery?

Anesthesia for Parathyroid Surgery

General anesthesia with endotracheal intubation is the recommended anesthesia regimen for parathyroid surgery, with modifications for nerve monitoring and consideration of regional anesthesia in select cases.

Preoperative Considerations

• Airway Assessment:

  • Evaluate for tracheal deviation or compression from large goiters
  • Assess vocal cord mobility (abnormal mobility may indicate existing recurrent laryngeal nerve impairment)
  • Communicate findings to anesthesiologist to plan appropriate airway management 1

• Nerve Monitoring Requirements:

  • If intraoperative nerve monitoring is planned, avoid long-acting neuromuscular blocking agents
  • Alert anesthesiologist preoperatively about nerve monitoring needs 1
  • Accurate endotracheal tube electrode placement is critical for effective monitoring

Anesthetic Technique Options

1. General Anesthesia (Primary Recommendation)

• Induction:

  • Propofol for induction
  • Short-acting opioids (e.g., fentanyl)
  • Short-acting muscle relaxant if needed (avoid long-acting agents if nerve monitoring planned)
  • Apply cricoid pressure during induction to reduce aspiration risk 1

• Maintenance:

  • Volatile anesthetic (e.g., desflurane) with oxygen
  • Desflurane offers advantages of faster recovery with time to eye opening of 4-5 minutes compared to other agents 2
  • Remifentanil infusion to attenuate coughing during emergence 1

• Airway Management:

  • Endotracheal intubation is standard for thyroid/parathyroid surgery 1
  • Ensure proper tube size and positioning, especially if nerve monitoring is used
  • Consider videolaryngoscopy for difficult airways

2. Regional Anesthesia (Alternative for Select Cases)

• Indications:

  • Patient preference
  • Significant cardiac or pulmonary disease
  • Need for early assessment of vocal cord function 3, 4

• Contraindications:

  • Patient apprehension
  • Deafness (inability to communicate during procedure)
  • Pre-existing recurrent laryngeal nerve palsy
  • Allergy to local anesthetics 5

• Technique:

  • Bilateral superficial cervical plexus block
  • Local infiltration at incision site with mixture of 0.25% lidocaine and 0.15% bupivacaine 3
  • Supplemental sedation as needed

• Advantages:

  • Shorter overall operating time (72 vs 90 minutes compared to general anesthesia)
  • Reduced postoperative pain medication requirements
  • Earlier return to work and better energy levels postoperatively 3, 4

Intraoperative Management

• Positioning:

  • Slight head elevation with neck extension
  • Avoid excessive neck extension in patients with cervical spine issues

• Monitoring:

  • Standard ASA monitors
  • Consider arterial line for patients with significant cardiovascular disease
  • If nerve monitoring is used, ensure proper functioning of monitoring equipment

• Fluid Management:

  • Maintain euvolemia
  • Monitor for hypercalcemia effects on cardiovascular function

Emergence and Extubation

• Deep vs. Awake Extubation:

  • Consider deep extubation in uncomplicated cases to minimize coughing and strain 1
  • For awake extubation, consider remifentanil infusion to suppress cough reflex while maintaining consciousness 1

• Difficult Extubation Plan:

  • Have difficult airway equipment readily available
  • Consider laryngeal mask airway exchange technique for high-risk cases 1
  • Follow Difficult Airway Society guidelines for extubation 1

Postoperative Considerations

• Calcium Monitoring:

  • Systematic assay of total blood calcium postoperatively
  • Hypocalcemia is common after parathyroidectomy, with lowest levels typically on postoperative days 2-3 6
  • Be prepared to treat symptomatic hypocalcemia with IV calcium

• Airway Assessment:

  • Evaluate for voice changes that may indicate recurrent laryngeal nerve injury
  • Any voice abnormalities should be evaluated by both anesthesiologist and surgeon 1

• Pain Management:

  • Multimodal analgesia with acetaminophen and NSAIDs
  • Patients receiving regional anesthesia typically require less postoperative pain medication 3

Special Considerations

• Patients with Renal Disease:

  • For secondary hyperparathyroidism in dialysis patients, consider cardiovascular comorbidities
  • In severe cardiac disease (marked aortic stenosis or severe left ventricular dysfunction), regional anesthesia may be preferred 6

• Difficult Airway:

  • Have difficult airway equipment available
  • Consider awake fiberoptic intubation for anticipated difficult airways
  • Follow Difficult Airway Society guidelines for management of unanticipated difficult intubation 1

While both general and regional anesthesia have been successfully used for parathyroid surgery, general anesthesia remains the standard approach for most patients, with regional anesthesia reserved for select cases with specific indications.