Position: Supine, Sitting / Beach Chair, arms tucked, head slightly extended
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Ask surgeon

Euthyroid – Patient should be euthyroid with resting heart rate < 85.

Preoperative Medications – Pt. Should still get their antithyroid and beta-blocker meds in the am.

Difficult airway possibility – These patients may have a goiter. If theres any question about the airway, use the glidescope.

NIMs Tube – check with the surgeon as they may prefer to monitor the laryngeal nerve. If so, you'll be using the NIMs ETT. In this case, you will not be using long-acting NMBs. If you do use a NIMs tube, many suggest using remifentanil (where not contraindicated). This has been shown to reduce the amount of volatile gases and improves hemodynamic stability (not as many big swings in BP). Postoperative pain is fairly easy to manage for these cases, so the benefit of a quick wakeup makes remifentanil a good choice. On wakeup, If using this approach, it is suggested that you offload as much volatile anesthetic as possible before discontinuing the remifentanil. This makes for a smoother wake-up and a more alert patient in post-op.

Blood pressure cuff – This is best placed on the leg (where not contraindicated). It is common for the surgeon to lean on the tucked arms. Alternatively, placement of a cuff on both arms could be done to change the cuff when the surgeon changes sides.

High Stimulation/Pain – The most stimulating part of the surgery is skin incision. Be prepared to manage with Propofol or a small amount of muscle relaxant just to get through opening.

Neo Drip – Keeping the patient deep without paralytics may necessitate a phenylephrine drip.

End of case – If the surgeon elected NOT to monitor the laryngeal nerve, they may want you to use a C-MAC/Glidescope to view the function of the vocal cords at the end of the case.

Smooth wakeup – no straining/coughing/bucking. Extubate deep if possible.

Elevate HOB 15-20 degrees – helps venous drainage and decreases blood loss.

Postoperative Pain – Ofirmev will be the analgesia of choice postoperatively. Hematomas are often blamed on NSAIDs (toradol), so avoiding them may be a good idea. Consult with the surgeon.

Postoperative bleed – can obstruct the airway. This is the reason the patient often stays overnight for monitoring.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Beach Chair/sitting position (general considerations): When putting the patient in this position, the staff will typically help lift the patient and exchange the head rest after intubation. Once the headrest is secured, the patient will be lifted to the sitting position. At this junction, make sure the circuit is disconnected and the ETT is free – this could easily extubate the patient if the ETT is still attached when lifting the patient. The degree of hemodynamic changes depends on the angle. If sitting at 45 degrees there will be minimal changes, whereas 90 degrees will reduce cardiac output by 20% (due to venous pooling in the legs). SVR will be 15-20 mm Hg lower at the circle of willis than at the cuff, which may compromise cerebral perfusion. Consider having ready ephedrine and phenylephrine to support blood pressures. For higher risk patients requiring an A-line, it is recommended to place the transducer at the level of the brain (level the transducer at the tragus). Make sure the head is in a neutral position (looking straight ahead and void of flexion/extension).