Endocrine Abstracts

Case history: A 32 year old female was admitted for an elective gynaecological procedure LLETZ (large loop excision of the transformation zone) under general anaesthesia as per patient”s request. An uncomplicated LLETZ procedure was performed. Post operatively, patient was found to be tachycardiac and had severe palpitations with nausea. She then reported that she had recently lost a significant amount of weight, had been suffering with anxiety, palpitations, and tremors prior to the operation. She had not disclosed any of her symptoms to a healthcare professional at any point prior to undergoing surgery. On examination, she was apyrexial, tachycardic, had a diffuse goitre with a thyroid bruit and evidence of exophthalmos. There was no evidence of heart failure and no cardiac murmurs. An urgent endocrinology review was sought, and the patient was also reviewed by the critical care outreach nurse and intensive care consultant before deciding to admit the patient overnight on a medical ward for observation.

Investigations: Urgent thyroid function tests were sent post operatively which showed T4 >100 and suppressed TSH of <0.01. The rest of the routine blood profile was unremarkable, including a septic screen. ECG showed sinus tachycardia. TSI was positive confirming Graves’ disease.

Results and treatment: She was commenced on propranolol and carbimazole for management of her thyrotoxicosis, as well as symptom control with anxiolytics and antiemetics. The patient complained of symptoms relating to pressure from her goitre and therefore a CT neck was performed which did not show any acute compromise. She was monitored under the endocrinology team until her symptoms settled and discharged with follow up.

Conclusions and points for discussion: Stress from surgery and general anaesthesia are known to precipitate thyrotoxicosis, and it is common practice to ensure patients are euthyroid before undergoing surgery. In addition to thyrotoxic crisis, further complications can arise from surgery in untreated hyperthyroidism. These complications can include intubation difficulties due to goitre and changes in metabolism of anaesthetic drugs. Pre-operative planning is vital to ensure any thyroid problems are investigated and treated prior to surgery. History and clinical examination are important aspects of the pre-operative planning process to aid in diagnosis of thyroid conditions which have potential to be exacerbated during surgery