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Anesthetic management for L&D of a morbidly obese patient with large retrosternal goiter
Abstract Number: 180
Abstract Type: Case Report/Case Series
INTRODUCTION: Large retrosternal goiters combined with morbid obesity can present an airway challenge in any patient. This challenge is exaggerated even more in pregnant patients. We present a case of the anesthetic management of a morbidly obese parturient with a large retrosternal goiter.
CASE: A 28 y.o. G5P3Ab1 presented at 39 weeks gest. age for anesthesia consultation before her induction of labor. She had SVD with epidural for all prior deliveries. PMH: Asthma, HTN, morbid obesity (height = 65", weight = 402 lb, BMI = 66.9), and a large retrosternal goiter. Pt. had the goiter since age 12, but was not worked up for it until 8/09 following admission for an MVA. She had dysphagia for solids, and 4 pillow orthopnea. She slept in the left lateral position to help alleviate her dyspnea. Pt. also had progressively worsening hoarseness for the past year.
TSH = 1.86. Thyroxine = 4.2.
CT Chest: Retrosternal thyroid mass, 3.3-3.7 cm. US Thyroid: B/L thyroid lobes enlarged, large solitary nodule in lower pole of left thyroid lobe.
ECHO nl with EF = 55%.
Image review with radiology revealed deviation of the trachea to the right that beginning approximately 2-3 cm below vocal cords. Tracheal compression was present at the point of deviation. At its narrowest point the trachea was approximately 10.7 mm in diameter.
Airway exam: Excess soft tissue, otherwise nl.
Pt. was examined jointly with ENT surgeon once again. An awake nasal fiberoptic exam revealed diffuse edema from nose to larynx. A multi-disciplinary discussion was held. Options discussed included vaginal delivery or C/S under neuraxial anesthesia, awake fiberoptic intubation for GA for C/S, and a combined C/S followed by thyroidectomy. It was agreed to try for vaginal delivery, but if C/S were needed ENT would come to OR to be available in case awake fiberoptic intubation was needed. Every effort would be made to avoid a STAT C/S.
On the day of induction a radial A-line was inserted. Continuous spinal was attempted, but unable to get CSF, so epidural was placed. Pt. tolerated L&D well and delivered 11 hours later. Pt. was encouraged to use incentive spirometry in the post-delivery period.
DISCUSSION: A retrosternal goiter is present in 3-20% of patients requiring thyroidectomy. It can compress both airway structures and the central vasculature. It is associated with dyspnea, dysphagia, tracheal deviation/compression, SVC syndrome. Depending on the degree of extension into the thorax, a tracheostomy may not be possible. Pre-anesthetic assessment of these patients involves a careful airway examination, and assessment of the extent of goiter involvement with a CT scan. Careful attention must be made to assess for tracheomalacia. In addition to considering the need for intubation and technique of intubation, the possible need for post-op mechanical ventilation must also be considered. A multidisciplinary approach to these patients is important in providing optimal care.