Emergency Thyroidectomy in a Patient with Severe Upper Airway Obstruction Caused by Goiter: Case for Regional Anesthesia. Anesthetic Management
The patient was brought to the operating room and placed in a semirecumbent position. A Nellcor Puritan Bernett multiparameter patient monitor was applied. The pulse was 120 beats/min, blood pressure was 100/70 mmHg and peripheral arterial oxygen saturation was 92%, with the patient breathing oxygen-enriched air. A peripheral intravenous access was established and 0.9% saline commenced. This was followed by bilateral superficial plexus block performed by a consultant anesthetist (first author) as follows: the midpoint of the posterior border of the sternomastoid muscle was identified. From this point, 15 ml of 0.375% bupivacaine with 1:400,000 epinephrine was infiltrated along the posterior border of the muscle, 3 cm cephalad and caudad, to block the superficial branches of the cervical plexus. A further 3 ml of the solution was also infiltrated superficially above the muscle to block the transverse cervical nerves. The block was performed on both sides of the neck using a size 21-gauge hypodermic needle. This procedure was well tolerated by the patient. Surgical anesthesia was demonstrated in 15 minutes. The patient was positioned supine with the head supported on a head ring and elevated by about 25°. The classical thyroidectomy positioning, with the head fully extended with the aid of a shoulder pad, could not be effected because this position worsened the patient’s respiratory distress.
She was given oxygen by face mask throughout the period of surgery. Hemodynamics were stable. Operative findings included: huge multinodular goiter measuring 28 x 12 cm, with areas of calcification in the left lobe and retrosternal extension. The goiter infiltrated into the surrounding tissues, including the anterior wall of the trachea rings and the left internal carotid artery. The central portion of the thyroid gland was filled with purulent fowl-smelling exudates. The tracheal deviated markedly to the right, forming a c-shape. The trachea was inadvertently opened into during mobilization. At this point, a transtracheal injection of 4 ml 2% plain lidocaine was performed and a size 26G tracheostomy tube was inserted. The patient was also sedated at this point with diazepam 2.5 mg and pethidine 25 mg. This was repeated as required during the procedure. However, the anesthetist maintained communication with the patient throughout the surgery, which lasted three hours and was uneventful. Anesthesia was generally effective for the procedure. The total dose of sedation wasdiazepam 5 mg and pethidine 75 mg. The excised tissue weighed 850 g. The patient was observed in the recovery room for about one hour before being transferred to the intensive care unit (ICU). The hemodynamics remained stable in the ICU. Peripheral arterial oxygen saturation ranged from 94-95 on room air via tracheostomy tube. The patient was transferred to the ENT ward after 48 hours for better care of the tracheostomy. She, however, died of aspiration on the fifth postoperative day due to an incoordination in swallowing caused by associated postthyroidectomy recurrent laryngeal nerve palsy. Histology of the tumor showed a well-differentiated follicular carcinoma with areas of necrosis and calcification. Make your pharmacy dollar go further cefdinir 300mg