What are the potential post-operative complications to watch out for after a thyroidectomy?

Post-Thyroidectomy Monitoring: Critical Complications to Watch

The most life-threatening complication requiring immediate vigilance is postoperative hematoma causing airway compromise, which can develop rapidly and unpredictably within the first 24 hours, followed closely by hypocalcemia from hypoparathyroidism. 1

Immediate Life-Threatening: Hematoma with Airway Compromise

Incidence and Timing

• Postoperative hemorrhage occurs in 0.45-4.2% of cases 1
• Most hematomas develop within the first 24 hours, with the majority occurring within the first 6 hours 1
• Even small volumes can cause rapid airway obstruction requiring emergency intervention 1

Recognition: Use the DESATS Acronym 1

Monitor for these warning signs (any single sign warrants urgent senior review):

• D - Difficulty swallowing/discomfort
• E - Elevated early warning score (EWS/NEWS)
• S - Swelling at the surgical site
• A - Anxiety
• T - Tachypnea/difficulty breathing
• S - Stridor

Critical pitfall: Desaturation and increased oxygen requirements are LATE signs of airway compromise—act on earlier signs to prevent deterioration. 1

Essential Monitoring Requirements 1

• Wound inspection with every vital sign check
• Standard early warning scores (respiratory rate, heart rate, blood pressure, temperature, oxygen saturation, Glasgow Coma Scale)
• Pain scores
• Subtle signs: agitation, anxiety, breathing difficulty, discomfort

Emergency Preparedness 1

• Post-thyroid surgery emergency box must be at bedside during entire postoperative period, including transfers 1
• Emergency front-of-neck airway equipment (scalpel, bougie, tracheal tube) must be readily available on the ward 1
• If ANY concern for hematoma: arrange immediate senior surgical review (registrar or consultant level) 1
• If airway compromise signs present: open wound at bedside using SCOOP approach (Skin exposure; Cut sutures; Open skin; Open muscles—superficial and deep layers; Pack wound) 1, 2

Monitoring Duration

• Minimum 6 hours postoperatively before considering discharge (for day-case surgery) 1
• Preferably nurse patient in open ward or near nursing station for maximum visibility 1

Hypocalcemia and Hypoparathyroidism

Incidence 2, 3, 4

• Temporary hypoparathyroidism: 5.4-12% of patients
• Permanent hypoparathyroidism: 0.5-2.6% of patients (1.1-2.6% in some series)

Clinical Presentation 2, 3

Watch for these pathognomonic signs:

• Perioral numbness (highly specific for hypocalcemia)
• Peripheral tingling in extremities
• Muscle cramps
• Carpopedal spasm

Laboratory Monitoring 5, 2, 4

• Measure PTH at 10 minutes after skin closure (or within 6-8 hours postoperatively) 5, 6
• Check serum calcium every 6-8 hours during first 24-48 hours until stable 5, 2
• PTH <15 pg/mL indicates high risk for acute hypocalcemia 4
• PTH >20 pg/mL at 20 minutes: no intensive calcium monitoring required 5

Risk Factors 4, 6, 7

• Female sex (higher risk than males) 6, 7
• Bilateral thyroid operations 4
• Central neck dissection 4
• Malignancy (27% risk of mild hypocalcemia) 6
• Pre-operative vitamin D deficiency 5, 7
• Age >50 years 5
• Inadvertent parathyroid gland removal or autotransplantation 6

Prevention and Management 5, 4

• PTH ≥10 pg/mL: oral calcium supplementation only 5
• PTH <10 pg/mL or high-risk patients: prophylactic calcitriol AND calcium supplementation 5
• Patients with multiple risk factors should start calcium and vitamin D pre-operatively 5
• Immediate treatment for symptomatic hypocalcemia 5
• Monitor for rebound hypercalcemia to avoid metabolic and renal complications 4

Long-Term Follow-Up 5, 3

• Serum calcium at 3,6, and 12 months, then annually 5
• Permanent hypoparathyroidism (1.1-2.6%) requires lifelong calcitriol treatment 5, 3

Recurrent Laryngeal Nerve Injury

Incidence and Presentation 2, 3, 8

• Occurs in 3-3.4% of cases 2
• Presents with voice changes, hoarseness, and vocal fold immobility 3
• Does NOT cause perioral numbness or limb tingling (these are hypocalcemia symptoms) 3

Other Complications to Monitor

Wound Infection 2

• Standard surgical site monitoring applies

Surgeon Experience Factor 2, 3

• Surgeons performing >100 thyroidectomies/year: 4.3% complication rate 3
• Surgeons performing <10 procedures/year: 17.2% complication rate (4 times higher) 3

Critical Nursing Location 1

• Patient should be nursed where staff are trained in recognition and management of post-thyroidectomy hematoma 1
• Open wards allow other patients to alert staff during acute deterioration 1

Staff Training Requirements 1

• All staff potentially interacting with thyroidectomy patients must be trained to recognize hematoma 1
• Training should be repeated every 3 years minimum 1
• Includes ward staff, doctors of all grades, emergency department staff (for day-case centers) 1