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LETTER TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 114-115
 

Parathyroidectomy in an elderly patient with multiple comorbidities under cervical plexus block


Department of Anaesthesia, AIIMS, Rishikesh, Uttarakhand, India

Date of Web Publication28-Aug-2019

Correspondence Address:
Dr. Bhavna Gupta
Department of Anesthesia and Critical Care, AIIMS, Rishikesh, Utarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_34_19

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How to cite this article:
Gupta B, Upreti B, Patil AG, Nishith Govil PT. Parathyroidectomy in an elderly patient with multiple comorbidities under cervical plexus block. Indian Anaesth Forum 2019;20:114-5

How to cite this URL:
Gupta B, Upreti B, Patil AG, Nishith Govil PT. Parathyroidectomy in an elderly patient with multiple comorbidities under cervical plexus block. Indian Anaesth Forum [serial online] 2019 [cited 2019 Sep 22];20:114-5. Available from: http://www.theiaforum.org/text.asp?2019/20/2/114/265651




Sir,

A 60-year-old female weighing 38 kg had complaints of bone pain, weight loss, easy fatigability, and recurrent history of flank pain. She was a diagnosed case of hypertension, with a history of resting tremors, chronic obstructive pulmonary disease, and hyperthyroidism and was recently diagnosed to have  Parkinsonism More Details. She was on amlodipine, levodopa, carbidopa, trihexyphenidyl, bisphosphonates, propylthiouracil, inhaled corticosteroids, and levosalbutamol. Her investigations revealed parathormone levels 296.90 pg/ml, serum calcium 11.6 mg/dl, ionized calcium 1.62 mmol/l, phosphorus 2.3 mg/dl, Vitamin D3 7.2 ng/ml, and thyroid-stimulating hormone 0.3 μIU/ml. Ultrasound neck revealed multiple nodules in the bilateral thyroid lobes and a well-defined hypoechoic lesion in the inferior pole of left thyroid lobe. This case was taken up as a semiemergency and planned to be carried out under superficial and intermediate cervical plexus block using bupivacaine 0.5%. To allay anxiety, 1 mg midazolam was given, and as a part of preanesthetic medication, dexmedetomidine 0.7 μg/kg intravenous (iv) bolus was given, followed by infusion at a rate of 0.4 μg/kg/h. Bupivacaine 0.5% was injected bilaterally at two points approached by going just posterior and medial to the clavicular head of sternocleidomastoid muscle at a level midway between the mastoid process and clavicle. The first point injection was given after a pop was felt by penetrating cervical fascia (intermediate cervical plexus block) and the second point being superficially just medial and posterior to belly of sternocleidomastoid (superficial cervical plexus block) [Figure 1]. The patient was maintained on O2 by nasal prongs, dexmedetomidine infusion, and intermittent boluses of propofol 20 mg iv and fentanyl 25 μg iv. Intraoperative frozen section biopsy of the tissue revealed parathyroid with areas of calcification and parathormone (PTH) levels after removal of parathyroid was within normal limits. On follow-up, the patient was comfortable and pain-free, with a normal voice.
Figure 1: Left-sided parathyroidectomy being done under cervical plexus block

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Parathyroid adenomas are associated with decreased bone density, so careful patient positioning is important to prevent fractures. Severe hypercalcemia can occur on rare occasions and should be managed using iv bisphosphonates, calcitonin, and steroids.[1] Uncontrolled hypertension was one of the major concerns in this case, which was managed by the use of dexmedetomidine and fentanyl to diminish sympathetic response and labetalol to maintain blood pressure near baseline. In patients of parathyroid adenoma presenting with hypertension, abdominal scan is done to rule out pheochromocytoma associated with MEN2a. Adequate preparations were made to manage the precipitation of thyroid storm, which could have occurred on account of hyperthyroidism. Patients with Parkinson's disease can have pharyngeal muscle dysfunction, respiratory impairment due to rigidity and uncoordinated muscle movement, arrhythmias, muscle rigidity tremors, and confusion. Higher fentanyl doses and morphine can cause muscle rigidity; succinylcholine can possibly cause hyperkalemia; neuromuscular blocking drugs can mask tremors.[2],[3] All this was avoided by using cervical plexus block. In the postoperative period, special attention was paid to any possible voice change owing to recurrent laryngeal nerve injury.[4],[5] Cervical plexus block is an effective modality for anesthesia in surgeries on thyroid and parathyroid glands in patients suffering from multiple comorbidities.

Acknowledgment

We would like to acknowledge Dr. S. P. Agarwal, Plastic Surgeon (and his team), for excellent surgical skills, meticulous approach, and dedication toward patient's care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta B, Govil NP, Agarwal M, Saith V. Total intra-venous anesthesia for parathyroid adenoma in a child. APSP J Case Rep 2017;8:35  Back to cited text no. 1
    
2.
Nicholson G, Pereira AC, Hall GM. Parkinson's disease and anaesthesia. Br J Anaesth 2002;89:904-16.  Back to cited text no. 2
    
3.
Kumar V, Dayal N, Garg J. Anesthetic concerns in hyperparathyroidism: A report of three cases. Anaesth Pain Intensive Care 2019;23:74-6.  Back to cited text no. 3
    
4.
Suri KB, Hunter CW, Davidov T, Anderson MB, Dombrovskiy V, Trooskin SZ. Postoperative recovery advantages in patients undergoing thyroid and parathyroid surgery under regional anesthesia. Semin Cardiothorac Vasc Anesth 2010;14:49-50.  Back to cited text no. 4
    
5.
Kulkarni RS, Braverman LE, Patwardhan NA. Bilateral cervical plexus block for thyroidectomy and parathyroidectomy in healthy and high risk patients. J Endocrinol Invest 1996;19:714-8.  Back to cited text no. 5
    


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