What is the recommended anesthesia induction regimen for a 23-year-old male undergoing a thyroidectomy?

Anesthesia Induction for Thyroidectomy in a 23-Year-Old Male

For a 23-year-old male undergoing thyroidectomy, the recommended anesthesia induction regimen includes propofol 2-2.5 mg/kg IV with routine use of an intubating bougie, preceded by application of cricoid pressure to reduce aspiration risk. 1, 2

Pre-induction Considerations

• Thorough airway assessment is essential before thyroidectomy, including evaluation of neck mobility, mouth opening, thyromental distance, and any signs of tracheal deviation or compression 1
• Communicate with the surgical team preoperatively about any special monitoring requirements, particularly if recurrent laryngeal nerve monitoring will be used, as this will affect choice of muscle relaxants 1
• If nerve monitoring is planned, long-acting paralytic agents are absolutely contraindicated 1
• Position the patient supine with neck extended to ensure optimal exposure 1

Induction Medications and Dosing

• Propofol 2-2.5 mg/kg IV is the recommended primary induction agent for this healthy young adult 2
• Alternative option is etomidate 0.3 mg/kg IV if hemodynamic stability is a particular concern 3
• Opioid (fentanyl 1-2 mcg/kg or remifentanil infusion) should be administered for analgesia 2, 4
• Short-acting muscle relaxant (if nerve monitoring is not planned) to facilitate intubation 1

Airway Management Technique

• Apply cricoid pressure during induction to reduce aspiration risk 1
• Routine use of an intubating bougie is recommended to optimize first-pass intubation success 1
• Consider videolaryngoscopy for first intubation attempt, especially if any predictors of difficult airway are present 1
• Limit tracheal intubation attempts to three, with optimization between attempts 1
• Confirm correct tube placement with clinical assessment and waveform capnography 1

Special Considerations for Thyroidectomy

• Accurate endotracheal tube placement is critical when nerve monitoring is used; improper electrode placement can lead to false monitoring security 1
• Have difficult airway equipment readily available, as thyroid pathology may cause tracheal deviation or compression 1
• Consider administering dexamethasone (0.15-1.0 mg/kg, maximum 8-25 mg) to reduce post-operative laryngeal edema 5
• Prepare for potential post-operative complications, particularly neck hematoma, which can cause rapid airway compromise 1

Post-Induction Management

• Maintain anesthesia with propofol infusion (100-200 mcg/kg/min) or inhalational agent with remifentanil 2
• Consider multimodal analgesia approach with pre-incision wound infiltration using 5 ml of 0.5% ropivacaine with epinephrine (1:200,000) to improve post-operative pain control 4
• Administer flurbiprofen axetil 100 mg IV approximately 20 minutes before the end of surgery for enhanced post-operative analgesia 4

Potential Complications and Management

• Be vigilant for signs of post-thyroidectomy hematoma (DESATS: difficulty swallowing/discomfort, elevated early warning score, swelling, anxiety, tachypnea/difficulty breathing, stridor) 1
• Have emergency front-of-neck airway equipment immediately available in case of post-operative airway compromise 1
• If hematoma with airway compromise occurs, follow the SCOOP approach: skin exposure, cut sutures, open skin, open muscles, pack wound 1
• Monitor for recurrent laryngeal nerve injury, which may manifest as voice changes post-operatively 1

Pitfalls to Avoid

• Avoid long-acting neuromuscular blocking agents if nerve monitoring is planned, as this will interfere with monitoring accuracy 1
• Do not remove cricoid pressure prematurely, but be prepared to release it if laryngoscopic view is difficult 1
• Avoid excessive neck manipulation during intubation to prevent disruption of thyroid pathology 1
• Be cautious with endotracheal tube cuff pressure, as placement adjacent to the recurrent laryngeal nerve may cause temporary voice dysfunction 1