Pre-operative preparation
1.General treatment and related examination are shown in the examination items of thyroid tumor.
2.Conventional preoperative treatment can take thiourea drugs, generally not less than 3 months; 2-3 weeks before surgery add compound iodine solution, 10 drops each time, 3/d, after 1 week of combined treatment, stop using thiourea drugs.
3, can not tolerate conventional medication or urgent surgery, available larger doses of propranolol (insulin) for preoperative preparation, usage is 40 ~ 80mg, 1/6h, continuous 4 ~ 7d, 1-2h before surgery and then oral 1 time. However, it is best to use it in combination with compound iodine solution. Propranolol is contraindicated in patients with bronchial asthma and heart block.
4. Patients with mild hyperthyroidism (basal metabolic rate <30%, pulse rate <100/min) can also be prepared with compound iodine solution alone, 10 drops each time, 3/d, for 2-3 weeks.
5.Patients with heart failure may be considered for simultaneous administration of digitalis preparations.
6. The conditions for surgery are: the patient’s pulse rate drops below 90/min after appropriate drug treatment, the basal metabolic rate drops to normal and more stable, the heart function is normal or has been compensated, the liver and kidneys are not dysfunctional, there are no other systemic active disorders, the sympathetic nervous system excitatory symptoms have been controlled, weight gain, the thyroid gland has shrunk, hardened, the tremor disappears, and the murmur is reduced. If the above conditions are met, surgery can be performed.
7. Other preoperative preparations are the same as those for major neck surgery. 200-600ml of blood should be prepared and appropriate amount of sedation should be used.
Anesthesia requirements
Cervical plexus nerve block; if the thyroid gland is large, especially if there is pressure on the trachea, endotracheal intubation should be used for general anesthesia.
Intraoperative points of attention
1. When operating on hyperthyroidism, one should be familiar with the anatomical structures in and around the thyroid gland. Intraoperative care should be taken not to damage the superior laryngeal nerve and the recurrent laryngeal nerve, to prevent removal of the parathyroid gland, and to prevent hemorrhage and accidental injury to nearby nerves when dealing with the superior thyroid artery and the inferior thyroid artery.
2. In accordance with the patient’s age and thyroid function, retain an appropriate amount of tissue from the posterior medial portion of the thyroid gland, generally leaving about the size of the end of the adult index finger.
3. When dealing with the superior thyroid artery, it should be close to the thyroid gland to avoid injury to the superior laryngeal nerve (Figure 13-2-3). The inferior thyroid artery can be treated by ligating the small and large branches entering the gland within the envelope or by ligating the trunk without cutting it off; the thyroid gland should be wedge-shaped and the posterior medial envelope should be preserved to avoid injury to the recurrent laryngeal nerve and parathyroid glands. For cervical plexus block anesthesia, if there is suspicious nerve tissue during surgery, try to clip it gently first, observe the pronunciation, and then decide whether to cut it off or not.
If necessary, hydrocortisone 100-200mg can be administered intraoperatively to avoid postoperative laryngeal edema, which may lead to respiratory difficulties.
5.Check the excised thyroid tissue in detail. If parathyroid glands are found, they should be cut into thin slices and immediately transplanted in the muscle layer of the neck.
6. Thoroughly stop bleeding and place a latex tube cut in half on each side of the trachea for drainage or use other fine tubes for negative pressure suction before suturing the incision.
Postoperative treatment
1.After surgery, give a liquid diet, and give intravenous fluids as appropriate, paying attention to prevent infusion reaction, so as not to induce thyroid crisis. Brake the head.
2. Give necessary sedatives, analgesics and appropriate amount of antibiotics.
3.During the initial 24h, pay close attention to the patient’s breathing, pulse and blood pressure. If there is respiratory distress, check for incisional bleeding, laryngeal edema and vocal cord paralysis, remove sutures if necessary, open the incision and perform hemostasis or tracheotomy. Pay attention to the presence of choking and coughing after eating.
4. Closely observe the amount of trauma drainage fluid and its nature. If there are no special circumstances, drainage is usually removed 24-48h after surgery.
5.Continue to take compound iodine solution orally, 10 drops each time, 3/d; or propranolol, 20~40mg, orally, 3/d. Generally stop taking the drug about 7d after surgery.
6. Pay attention to the presence of numbness around the mouth and lips and extremities, and the presence of hand and foot twitching. If it occurs, take calcium lactate orally, or in emergency, inject 10ml of 10% calcium gluconate intravenously and measure blood calcium and phosphorus. If the symptoms are heavy or persistent, osteoporosis or dihydrotestosterol 0.5ml~3ml/d can be given, which can have good effect.
7. Thyroid crisis mostly occurs within 36h after surgery, and the main symptoms are rapid pulse rate, elevated blood pressure, hyperthermia, irritability, vomiting, watery diarrhea, delirium, and even coma. The following therapeutic measures can be taken.
(1) Sedation: Valium orally or intramuscularly; hibernation drugs can also be used.
(2) cooling: ethanol rubbing bath or ice bag cold compress, ice water enema if necessary, combined with hibernation drugs.
(3) Intravenous fluids to maintain water and electrolyte balance.
(4) Oral administration of compound iodine solution 1~2ml, 3~4/d, until the critical symptoms disappear. In case of emergency, inject 30-50 drops of compound iodine solution (1.8-3ml) in 5% glucose saline 500-1000ml, or sodium (potassium) iodide 1-2.5g.
(5) When the situation permits, take propylthiouracil (400mg for the first time, followed by 200mg for 1/6 to 8h) or tabazol (40mg for the first time, followed by 20mg for every 6 to 8h) orally before the administration of iodine lh.
(6) Use anti-sympathetic drugs, such as reserpine 1~2.5mg, intramuscularly, 1/8h; propranolol 20mg, orally, 1/4h. In case of emergency, use propranolol 5mg dissolved in 25% glucose solution 20~100ml slowly by sedation or drip, if necessary, under ECG supervision.
(7) Give hydrocortisone 200-400mg, IV, or dexamethasone 10-20mg, IV, 1/d.
(8) Other: administer oxygen, large amount of vitamin B, drugs to prevent and control heart failure, etc.
(8) Before discharge, make vocal cord examination if necessary.