PIG Meeting: 1st April 2021

79yo lady

Background

• Goitre
  • Previous hyperthyroidism, treated with radioactive iodine, euthyroid since
  • Investigated for hot flushes and sweating, multi nodular goitre found on CT, 5mm retrosternal component
  • Surgical review – thyroid barely palpable, minimal symptoms, booked for thyroidectomy

• Day of surgery:
  • ACE-i withheld, SBP 220-250 with nil apparent anxiety
  • ECG normal, patient asymptomatic
  • Nil thyroid imaging since 2019, TFTs last checked in 2015
  • Surgery cancelled

Issues

• Is surgery appropriate in this patient?
  • A respectful discussion with the surgeon can occur in this context, to explore the anaesthetist’s concerns – minimally symptomatic thyroid disease in elderly patient
  • Not uncommon for patients to be booked well in advance of surgery due to long wait-lists. Repeat surgical reviews (in the absence of new or worsening issues) would add substantial burden to the system.
• Could this outcome have been avoided with a face-to-face review?
  • Consider testing TSH peri-operatively if not done within 12 months if stable disease or sooner if frequent medication changes required/new cardiac arrhythmias/or signs and symptoms of thyroid disease (see attached DRAFT pre-operative pathology testing guidelines)
  • BP checks in clinic are controversial, with AAGBI guidelines suggesting that values obtained in the community are more appropriate, however a F2F review would have prompted a discussion with the GP if similar values to this were obtained.
  • We are reviewing our practice in the Preoperative clinic to determine how best to capture BP data for patients having phone consultations.

• BP guidelines?
  • AAGBI guidelines suggest community based BP readings of <160 SBP and <100 DBP should be achieved before elective surgery, while < 180 SBP and <100 DBP are acceptable in clinic or on day of surgery if prior BP readings are unknown.