Objectives
Physiology
Risk factors for hypocalcemia
Management strategies
Passive vs. active
Treatment of hypocalcemia
Ted H. Leem, MD MS
Assistant Professor
Division of Head and Neck Oncology
Otolaryngology
Head and Neck
Surgery
Physiology
Functions
Bone and teeth
Nervous system
Muscular tone and contraction
Clotting cascade
Otolaryngology
Head and Neck
Surgery
Kronenberg: Williams Textbook of Endocrinology, 11 ed.
10/23/2010
Post-surgical Hypocalcemia
Hypoparathyroidism
Thyroid surgery
Reoperative procedures
Temporary 10%-40%
Parathyroid surgery
Permanent 1%-3%
Who is at risk?
Previous surgery
Renal hyperparathyroidism
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Complications of Thyroid Surgery. In Complications of Head and Neck Surgery. Ed Eisele D. and R. Smith. 2nd ed. 2009
Complications of Parathyroid Surgery. In Complications of Head and Neck Surgery. Ed Eisele D. and R. Smith. 2nd ed. 2009
Wait and
see
Otolaryngology
Head and Neck
Surgery
Selective
treatment
Costly
Empiric
treatment
Otolaryngology
Head and Neck
Surgery
10/23/2010
Monitoring Calcium
Serum calcium measurements
Most common
Correct for hypoalbuminemia
Add 0.8 for every 1g/dL of albumin that is missing
0.8[4 (g/dL) - albumin (g/dL)] + Ca (mg/dL)
Cheaper
Ionized calcium
Sick patients
Calcium drip
Special handling
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Costly
Calvi LM, Bushinsky DA. When is it appropriate to order an ionized calcium? J Am Soc Nephrol. 2008. Jul;19(7):1257-60.
Serum Calcium
Serum Calcium is adequate to monitor for
hypocalcemia
Using this algorithm
Safe and early discharge
Decrease hospital stays
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Nahas et al. Laryngoscope 2006.
10/23/2010
Selective Treatment
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Jumaily JS et al. Prediction of hypocalcemia after using 1- to 6-hour postoperative PTH and calcium levels. Head Neck. 2010 Apr;32(4):427-34.
60% reduction
Outpatient surgery
100% sensitivity
100% specificity
100% positive-predictive value
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Jumaily JS et al. Prediction of hypocalcemia after using 1- to 6-hour postoperative PTH and calcium levels. Head Neck. 2010 Apr;32(4):427-34.
Jumaily JS et al. Prediction of hypocalcemia after using 1- to 6-hour postoperative PTH and calcium levels. Head Neck. 2010 Apr;32(4):427-34.
10/23/2010
UCLA Protocol
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Wiseman JE et al. An algorithm informed by the PTH level reduces hypocalcemic complications of thyroidectomy. World J Surg. 2010 Mar;34(3):532-7.
Prophylactic Treatment
Pre-emptive calcium, vitamin D, or both can
decrease the risk for hypocalcemia
Moore. J Am Coll Surg 1994;178:11-6
n = 706
Control
72
Calcium
288
Calcium + Vitamin
D
346
Non-randomized, observational
Hypocalcemia
31%
Otolaryngology
Head and Neck
Surgery
Hypocalcemia
19%
Hypocalcemia
4%
Otolaryngology
Head and Neck
Surgery
International Journal of Surgery. 2010
10/23/2010
Empiric Treatment
Treatment
Vitamin D
Safe
Magnesium
PTH
Cost savings
Protocols vary
3g Calcium carbonate/day
Vitamin D vs. calcitriol
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Treatment
Oral Calcium
Goal: low-normal
Severe hypocalcemia
IV Calcium gluconate
peripherally
Gas
Bloating
Constipation
Symptomatic
hypocalcemia
IV or PO
2 g 10 g of elemental
calcium divided BID or
TID
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Office of Dietary Supplements. Nih.gov 2010
10/23/2010
Calcium Preparations
Otolaryngology
Head and Neck
Surgery
Vitamin D
Calcium salt
% elemental
calcium
Other
Carbonate
40
Requires
acid
Phosphate
38
Acetate
25
Citrate
21
Lactate
13
Gluconate
Glubionate
Mechanism
Increases enteric calcium absorption 400%
Stimulates bone resorption in response to PTH
Calcitriol 1,25(OH)2D3
Active and most potent
Added empirically or when oral calcium is inadequate
Better GI
tolerance
Otolaryngology
Head and Neck
Surgery
Magnesium
Follow-up
Endocrinology Colleagues
IV
Magnesium chloride 4 g IV
Consideration of autotransplantation of
cryopreserved glands
PO Magnesium
Diarrhea
Magnesium citrate is often used for bowel prep
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Kronenberg: Williams Textbook of Endocrinology, 11 ed.
10/23/2010
Cryopreservation
PTH
Expensive
Injected
Otolaryngology
Head and Neck
Surgery
Otolaryngology
Head and Neck
Surgery
Cohen MS et al. Long-term functionality of cryopreserved parathyroid autografts: a 13-year prospective analysis. Surgery. 2005
Summary
Calcium homeostasis is important for normal
function
Post-surgical hypocalcemia is common and
predictable
Post-operative serum calcium and PTH can be
used to risk stratify those at greatest risk
Prophylactic treatment of these individuals will
improve patient care
Do not forget to involve Endocrinology
colleagues
Otolaryngology
Head and Neck
Surgery