Perioperative management of patient with newly diagnosed hyperthyroidism

Hyperthyroidism is a clinical condition caused by increased synthesis and secretion of thyroid gland hormones that affect the whole body. Its multi-organ effects and complications require adequate management in perioperative period. A 50-year-old patient was consulted to internal medicine for perioperative management for ureteroscopy procedure. Patient reported bilateral flank pain, nausea, vomiting, palpitation, and history of weight loss. Patient also has history of diabetes mellitus, on gliquidone. Physical examination presented pale conjunctiva, tachycardia, and soft tremor. Thyroid gland was enlarged, tender on palpation, no bruits were found. Peripheral blood count and thyroid function evaluation showed elevated white blood count, severe anaemia, elevated blood urea nitrogen and creatinine, decreased thyroid stimulating hormone and elevated free thyroxine. Ultrasound of thyroid gland concluded multiple cystic nodules. Wayne’s index is 20. Patient was administered 2 bags of packed red cells, insulin injection, propylthiouracil 3×200 mg, propranolol 3×10 mg, and hydrocortisone injection 2×100 mg prior to surgery. Patients with hyperthyroidism are recommended to be in euthyroid state prior to surgery. Hyperthyroid patients requiring emergent/urgent surgery are administered a combination of antithyroid drugs, corticosteroids, and beta-blockers to prevent thyroid storm. Propylthiouracil prevents production of thyroid hormones, corticosteroids inhibit hypermetabolism, and beta-blockers prevent sympathetic stimulation. Surgery was successful and thyroid storm did not occur.