A patient‐centred approach to sequential elective caesarean section and total thyroidectomy

Abstract

Sequential surgery (i.e. consecutive procedures within the same operating theatre admission) poses challenges which demand multidisciplinary teamwork. Subspecialist anaesthetic expertise is required, different surgical teams need to coordinate patient care, and most importantly, the patient's wishes must be taken into consideration.We describe the management of a woman who underwent sequential elective caesarean section and total thyroidectomy at 38 weeks gestation in whom a thyroid carcinoma had been diagnosed in the second trimester of pregnancy, requiring total thyroidectomy.To ensure optimal anaesthetic options for each procedure, separately and in combination as recommended in the literature [1], two anaesthetists collaborated: one with expertise in obstetric anaesthesia and the other in head and neck surgery. The patient requested to be awake for her baby's birth as she had concerns about her baby being exposed to general anaesthesia.Advance multidisciplinary discussions involving anaesthetists, obstetricians, endocrine surgeons, midwives, operating theatre staff, paediatricians and ward staff identified and mitigated numerous peri-operative challenges.Pre-operatively, the decision to perform the procedures in a general surgical theatre meant obstetric and paediatric staff needed to work outside their usual environment. This issue was mitigated by coordination and equipment preparation.Intra-operatively, the team started with a caesarean section under spinal anaesthesia, followed by thyroidectomy under general anaesthesia using a total intravenous technique. Spinal anaesthesia was performed using hyperbaric bupivacaine 11 mg and diamorphine 300 lg. A noradrenaline infusion was delivered via a peripheral venous cannula. This was commenced at 0.21 lg.kg -1 min -1 , and weaned off before the end of the caesarean section. Noradrenaline was chosen due to a lower risk of bradycardia compared with phenylephrine, so that it could easily be recommenced if required during her total intravenous general anaesthetic. Noradrenaline is being used more frequently in obstetric anaesthesia, and it has been shown to be noninferior to phenylephrine [2]. The patient saw and held her baby as per her wishes.Then, general anaesthesia was induced with a target-controlled infusion of propofol, titrated to maintain a bispectral index between 30 and 60. This approach was chosen for its more favourable recovery profile compared with inhalational anaesthesia.It allows a faster return to full consciousness and reduces the risk of postoperative nausea and vomiting. In addition, it reduces the risk of uterine atony, and addresses concerns of possible increased risk of metastatic spread of malignant cells during cancer surgery [3,4].Regarding postoperative care, the obstetricians advocated for admission to the postpartum ward with midwifery support.However, the surgical team preferred a surgical ward to monitor for post-thyroidectomy complications. The consensus was that the patient should be admitted to the postpartum ward with regular sen...

How to write a case report in anaesthesia and peri‐operative medicine

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