Perioperative Management of Total Knee Replacement and Total Hip Replacement in Hypothyroidism Patients_West China Medical Journal

Authors：

ZHOU Chengpei , HE Junhui ,  ZHOU Zongke , YANG Jing , SHEN Bin , KANG Pengde , PEI Fuxing

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

ZHOU Zongke, Email: zhoucpei@126.com.cn

Keywords：

甲状腺功能减退症; 全髋关节置换术; 全膝关节置换术; 围手术期

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目的　探讨髋或膝关节置换术（THR/TKR）并存甲状腺功能减退症（甲减）患者围手术期的处理策略。方法　2009年1月－2011年12月收治30例行THR/TKR并存甲减患者，其中男8例，女22例，平均年龄62.4岁。处理要点包括术前纠正甲状腺激素水平；术中缩短手术时间，减少出血量，选择性应用糖皮质激素；术后补充甲状腺激素，预防感染及深静脉血栓形成，改善胃肠功能。评价指标包括围手术期血压、心率变化，胃肠功能状况，切口愈合时间，甲状腺功能水平，黏液性水肿昏迷等并发症发生率；术前及术后Harris及特种外科医院评分系统（HSS）评分等。结果　术后心率变化大，非致命性心律失常者20例；血压控制平稳；术后甲状腺功能变化不明显，无黏液性水肿昏迷、心包积液及呼吸窘迫等严重并发症发生。随访1个月，术前HSS评分平均28分，术后86分；术前Harris评分平均32分，术后87分。结论　术前控制血清促甲状腺素在0.5～3.0 mU/L以内，总甲状腺素、游离甲状腺素至正常水平，是有效预防甲减患者THR/TKR围手术期并发症的关键；综合应用左甲状腺素片、糖皮质激素和抗凝治疗是安全渡过围手术期的重要保证。

Citation： ZHOU Chengpei,HE Junhui,ZHOU Zongke,YANG Jing,SHEN Bin,KANG Pengde,PEI Fuxing. Perioperative Management of Total Knee Replacement and Total Hip Replacement in Hypothyroidism Patients. West China Medical Journal, 2012, 27(5): 665-669. doi: Copy

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2.	Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism[J]. Endocrinol Metab Clin N Am, 2003, 32(2): 503-518.
3.	Venkatesan T, Thomas N, Ponniah M, et al. Oral triiodothyronine in the perioperative management of central hypothyroidism[J]. Singapore Med J, 2007, 48(6): 555-558.
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7.	Devdhar M, Ousman YH, Burman KD. Hypothyroidism [J]. Endocrinol Metab Clin North (Am), 2007, 36(3): 595-615.
8.	Ringel MD. Management of hypothyroidism and hyperthyroidism in the intensive care unit [J]. Crit Care Clin, 2001, 17(1): 59 -74.
9.	Schiff R, Welsh GA. Perioperative evaluation and management of the patient with endocrine dysfunction [J]. Med Clin North Am, 2003, 87(1): 175-192.
10.	Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone reduction on perioperative outcome [J]. Anesth Analg, 1997, 85(1): 30-36.
11.	Mercado DL, Petty BG. Perioperative medication management [J]. Med Clin North Am, 2003, 87(1): 41-57.
12.	Spell III NO. Stopping and starting medications in the perioperative period [J]. Med Clin North Am, 2001, 85(5): 1127-1128.
13.	Wellby ML, Kennedy JA, Barreau PB, et al. Endocrine and cytokine changes during elective surgery [J]. J Clin Pathol, 1994, 47(11): 1049-1051.
14.	Girvent M, Maestro S, Hernandez R, et al. Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation [J]. Surgery, 1998, 123(5): 560-567.
15.	Wartofsky L, Burman KD. Alterations in thyroid function in patients with systemic illness: the “euthyroid sick syndrome” [J]. Endocr Rev, 1982, 3(2): 164-217.
16.	Stathatos N, Levatan C, Burman KD, et al. The controversy of the treatment of critically ill patients with thyroid hormone [J]. Best Pract Res Clin Endocrinol Metab, 2001, 15(4): 465-478.
17.	Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders [J]. Anesthesiology Clin North Am, 2004, 22(1): 93-123.
18.	Simone JV, Abildgaard CF, Schulman I. Blood coagulation in thyroid dysfunction [J]. N Engl J Med, 1965, 273(20): 1057-1061.
19.	Dalton RG, Dewar MS, Savidge GF, et al. Hypothyroidism as a cause of acquired von Willebrand’s disease [J]. Lancet, 1987, 1(8540): 1007-1009.
20.	Loeliger EA, van der Esch B, Mattern MJ, et al. The biological disappearance rate of prothrombin, factorsⅦ, Ⅸ, and Ⅹ from plasma in hypothyroidism, hyperthyroidism and during fever[J]. Thromb Diath Hemorrh, 1964, 10: 267-277.

1. 　中华医学会内分泌学分会《中国甲状腺疾病诊疗指南》编写组. 甲状腺疾病诊治指南甲状腺功能减退症[J]. 中华内科杂志, 2007, 46(11): 967-971.
2. 　Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism[J]. Endocrinol Metab Clin N Am, 2003, 32(2): 503-518.
3. 　Venkatesan T, Thomas N, Ponniah M, et al. Oral triiodothyronine in the perioperative management of central hypothyroidism[J]. Singapore Med J, 2007, 48(6): 555-558.
4. 　中华医学会骨科学分会. 中国骨科大手术静脉血栓栓塞症预防指南[J]. 中华关节外科杂志(电子版), 2009, 3(3): 70-72.
5. 　Kohl BA, Schwartz S. How to manage perioperative endocrine insufficiency [J]. Anesthesiology Clin, 2010, 28(1): 139-155.
6. 　万圣云, 朱宗超, 王光升. 外科病人并甲低的围手术期处理 [J]. 医师进修杂志, 1995, 18(10): 26-27.
7. 　Devdhar M, Ousman YH, Burman KD. Hypothyroidism [J]. Endocrinol Metab Clin North (Am), 2007, 36(3): 595-615.
8. 　Ringel MD. Management of hypothyroidism and hyperthyroidism in the intensive care unit [J]. Crit Care Clin, 2001, 17(1): 59 -74.
9. 　Schiff R, Welsh GA. Perioperative evaluation and management of the patient with endocrine dysfunction [J]. Med Clin North Am, 2003, 87(1): 175-192.
10. 　Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone reduction on perioperative outcome [J]. Anesth Analg, 1997, 85(1): 30-36.
11. 　Mercado DL, Petty BG. Perioperative medication management [J]. Med Clin North Am, 2003, 87(1): 41-57.
12. 　Spell III NO. Stopping and starting medications in the perioperative period [J]. Med Clin North Am, 2001, 85(5): 1127-1128.
13. 　Wellby ML, Kennedy JA, Barreau PB, et al. Endocrine and cytokine changes during elective surgery [J]. J Clin Pathol, 1994, 47(11): 1049-1051.
14. 　Girvent M, Maestro S, Hernandez R, et al. Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation [J]. Surgery, 1998, 123(5): 560-567.
15. 　Wartofsky L, Burman KD. Alterations in thyroid function in patients with systemic illness: the “euthyroid sick syndrome” [J]. Endocr Rev, 1982, 3(2): 164-217.
16. 　Stathatos N, Levatan C, Burman KD, et al. The controversy of the treatment of critically ill patients with thyroid hormone [J]. Best Pract Res Clin Endocrinol Metab, 2001, 15(4): 465-478.
17. 　Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders [J]. Anesthesiology Clin North Am, 2004, 22(1): 93-123.
18. 　Simone JV, Abildgaard CF, Schulman I. Blood coagulation in thyroid dysfunction [J]. N Engl J Med, 1965, 273(20): 1057-1061.
19. 　Dalton RG, Dewar MS, Savidge GF, et al. Hypothyroidism as a cause of acquired von Willebrand’s disease [J]. Lancet, 1987, 1(8540): 1007-1009.
20. 　Loeliger EA, van der Esch B, Mattern MJ, et al. The biological disappearance rate of prothrombin, factorsⅦ, Ⅸ, and Ⅹ from plasma in hypothyroidism, hyperthyroidism and during fever[J]. Thromb Diath Hemorrh, 1964, 10: 267-277.

West China Medical Journal

Perioperative Management of Total Knee Replacement and Total Hip Replacement in Hypothyroidism Patients

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