Intraoperative Hemodynamics of Hyperthyroidism: Controlled versus Uncontrolled Graves Disease

Previous studies by high-volume endocrine surgeons have shown that patients with hyperthyroidism can safely undergo total thyroidectomy without being rendered euthyroid, with no increase in postoperative complications. This study aimed to further characterize perioperative hemodynamic management in hyperthyroid patients to inform clinical decision-making and risk mitigation strategies.

We performed a retrospective review of patients who underwent thyroidectomy for hyperthyroidism between December 2016 and January 2024 at a quaternary academic referral center. All surgeries were performed by high-volume endocrine surgeons. Patients were stratified by their preoperative thyroid status (euthyroid versus hyperthyroid) based on the most recent laboratory values obtained within 48 h of the operation; hyperthyroidism was defined as free triiodothyronine >4.4 ng/dL or free thyroxine >1.64 ng/dL. We compared the intraoperative heart rate (HR) and blood-pressure patterns and the use of antihypertensive medications administered during surgery between the two groups. Statistical analyses included chi-square, t-tests, and logistic regression.

Among 242 patients, 23.1% (n = 56) were hyperthyroid. The euthyroid group was older (50.3 versus 42.6 y, P = 0.004). Most patients were females (76.9%) and American Society of Anesthesiologists class III. No patients developed thyroid storm. Hyperthyroid patients had higher HR at induction (92 versus 79 bpm) and intraoperatively (110 versus 101 bpm, both P < 0.001). Intraoperative antihypertensive use was more common in the hyperthyroid group (56.8% versus 22.7%, P < 0.001). No differences were observed in intraoperative blood pressure trends, steroid or vasopressor use, arrhythmias, or estimated blood loss.

Hyperthyroid patients exhibit higher HRs and increased need for intraoperative antihypertensives but do not experience excess perioperative risk. With careful intraoperative monitoring, thyroidectomy can be performed safely without requiring biochemical euthyroidism.