Laryngospasm, bronchospasm or epileptic crises can also occur all of which compromising the patient's life [36,37]. It consists on the spasm of the hand and forearm due to the occlusion of the brachial artery when a blood pressure cuff is placed on the arm and inflated to 10 mm Hg above the systolic pressure during at least 2 minutes. The most frequent electrocardiographic findings are QTc and ST segments prolongation, T wave inversion and in severe cases, AV block or ventricular fibrillation [22,38].
In chronic hypocalcemia symptoms such as dry skin, rough hair or fragile nails are often more subtle. In spite of that, severe complications may appear in chronic cases such as papilledema, parkinsonism, subcapsular cataracts, calcification of the basal ganglia and intracerebral hemorrhages [22,38].
Other lab tests are important in the evaluation of the patient suspected with this condition: [9,10,22,33,38]. Serum iPTH levels take before, during and after thyroidectomy have been evaluated in different studies as a predictive factor for mild to severe post-surgical hypocalcemia and post-surgical hypoparathyroidism.
The decrease of the postoperative iPTH value compared with the preoperative, has been proven as a predicting factor of transient and permanent hypocalcemia [11,20,31]. Different values of iPTH defined as threshold taken at different latency times which can be as early as 5 minutes after thyroidectomy intraoperative iPTH , in the first post-surgical hour peri-operative iPTH or at 24 hours post-surgical post-operative iPTH , have been reported. Prevention of postsurgical hypoparathyroidism: As previously described, the insufficiency or deficiency of VD is an independent preoperative predictor Figure 1 , contributing to postsurgical hypocalcemia.
Its measurement is suggested routinely as a first step in preventing post-operative hipocalcemia [30,31]. The high cost is decreasing progressively, and its benefit supports its routine use. Figure 2. Approach to the acute patient with hypocalcaemia after thyroid surgery. It is recommended to follow up and educational interventions to promote a healthy lifestyle with appropriate diet; improve adherence, and the proper use of drug therapy.
It is a known fact to every surgeon that in order to prevent postoperative hypoparathyroidism while performing thyroid surgeries, the best effort must be made to avoid any kind of damage, either directly to the glands or to the blood supply of the parathyroids. A thorough knowledge of the anatomy and the most frequent variations of the location and blood supply to the glands on the part of the experienced thyroid surgeon is the best tool in preventing damage to the parathyroids and their function [55].
Identifying the location of the PGs and their major vessels particularly the inferior thyroid artery and its usual bifurcation, its relation to the RLN and its distal branches and trying to ligate them as distally as possible are the mainstay of a proper surgical technique.
Also, a plane of cold capsular dissection, and the use of ultrasound rather than mono or bipolar energy when needed, aid in the objective of preventing vascular compromise to the glands. Nevertheless, even when the surgeon is confident that the PGs are intact and viable at the completion of the procedure, hypocalcaemia may occur.
The mechanism of hypoparathyroidism after thyroidectomy is not entirely understood, but the manipulation of the PGs producing transient parathyroid insufficiency or reversible ischemia is commonly cited [56,57]. Based in the findings described above, many groups have developed protocols that include perioperative iPTH and calcium serum levels in order to classify their patients within risk groups and allowing either an early discharge or the establishing of an early in-hospital treatment for thyroidectomized patients using calcium supplements and adjusting surveillance.
This has reduced emergency room readmissions as well as prolonged unjustified hospitalizations, improving the quality of life and therefore reducing costs. Since there are different values in the protocols and articles reported, we present an algorithm based on the literature, adjusted to what is most frequently observed and recommended at our institutions.
Prophylactic supplementation of oral calcium from day 1 postoperative reduces the incidence of postoperative symptomatic hypocalcemia, length of hospital stays and the need for using parenteral calcium in the different schemes [58,59]. Once normalized, weekly monitoring of CSC for albumin and phosphorus and titrating doses according to the reports is the generalized use [14,18,57]. Detection, diagnosis and management of hypoparathyrodism : To assess the presence of hypoparathyroidism, the levels of iPTH, serum total calcium and albumin should be measured during the first 24 hours after surgery and the patients should be classified into 3 groups:.
If the patient shows a CSC between 7. High risk patient: If the values of CSC are below 7. If CSC levels is persistently below 7. EKG monitoring must be done during calcium infusion. It is also recommended to give vitamin D additional to calcium when the patient does not take vitamin D cholecalciferol supplements. Outpatient management of hypoparathyroidism : Patients who fail to show normal levels of CSC and symptoms of hypocalcemia persist can be used diuretic type thiazides if blood pressure is normal or elevated.
Thiazide diuretics lower urine calcium excretion because they enhance renal calcium reabsorption, at the distal tubule [62]. This inhibits NaCl resorption, promoting its excretion and decreasing the effective volume. The hypocalciuric effect of thiazides is not just secondary to the effective volume depletion but depends upon the levels of PTH near normal circulating hormone and producing hypercalcemia due to the calcium release from the bone and probably increasing PTH action in the bone and kidney [64,65].
Follow up with serum levels of calcium, phosphorus and creatinine should be done weekly or monthly during initial dose adjustments. Once the levels are stable, follow up can be done twice a year. Treatment with calcium and vitamin D may be challenging and lead to complications such as calcification in soft tissues, hypercalcemia and hypercalciuria. In response to PTH deficit in these patients, it has been considered since with the demonstration of doctor Albright , the utility of bovine PTH in the management of symptomatic hypocalcemia [66].
Many studies have been conducted with 2 molecules of recombinant human PTH, the amino terminal extreme, PTHR Teriparatide [67] and the complete molecule PTHR [68], both proving beneficial in maintaining serum calcium levels and bone mineral density in patients with postsurgical hypoparathyroidism refractory to calcium and VD treatment [69].
Treatment with PTHR evidenced an increase in serum calcium levels variable during the day with a peak at hours post injection, and increased activation of VD, 10 hours post administration [68].
Available PTHR with a shorter half life, requires administration every 12 hours, or subcutaneous infusion per pump [], while the molecule can be administered every 24 hours [73,74]. Its use as an adjunctive to treatment with VD and calcium in patients with postsurgical hypoparathyroidism was indicated only in patients which cannot be controlled with calcium plus VD or the active molecule of VD Calcitriol or alfacalcitriol , with the specification to individualize the treatment for each patient, given the evidence of increased risk of osteosarcoma in rats.
Hypocalcemia secondary to hypoparathyroidism after thyroidectomy is a frequent complication morbidity and mortality. Thyroidectomy: surgery to remove the entire thyroid gland. When the entire thyroid is removed it is termed a total thyroidectomy. When less is removed, such as in removal of a lobe, it is termed a partial thyroidectomy. This leads to a fall in parathyroid hormone PTH , which is important in regulating blood calcium levels. This usually resolves in days to weeks.
The rate of permanent hypocalcemia is thought to be. Vitamin D plays an essential role in maintaining calcium levels by increasing calcium absorption from the gut.
While rare, permanent hypoparathyroidism continues to be a real, clinical problem after thyroid surgery. If it appears that the parathyroid gland s will not be able to recover, surgeons may autotransplant one or more parathyroid glands into the muscles of the neck during surgery.
However, there remains considerable controversy and uncertainty among surgeons as to the best approach to reduce the risk of hypoparathyroidism when performing thyroidectomy. The incidence in children is higher than in adults, possibly related to the decreased incidence of thyroid surgery and therefore decreased experience among many pediatric thyroid surgeons. However, even in experienced surgical hands in adult patients, the risk of temporary hypoparathyroidism is high. Only a few studies have tried to report the risks of hypoparathyroidism.
The first paper reports on post-surgical hypoparathyroidism in children, while the second paper focuses on adults. World J Surg. Epub Feb PMID: Distal ligation of all terminal branches of the superior and inferior thyroid arteries, close to the thyroid capsule, enables reliable separation of all tissues carrying parathyroid gland away from the thyroid surface.
Continued dissection in this tissue, with the aim to identify all parathyroid glands may increase the risk of their mechanical injury or devascularization.
This findings suggest that sex female gender is a strong risk factor , surgical procedure and perioperative changes in serum calcium are the only factors among all variables examined that influence early hypocalcemia development.
All the risk factors detected in our study appear to be very common and not editable before nor during or after surgical procedure. In our experience, therefore, prophylaxis with calcium and Vit. Since when we started this prophylaxis we noticed a decreased length of stay and minimization of re-entry. Better consenting for thyroidectomy: who has an increased risk of postoperative hypocalcemia? Eur Arch Otorhinolaryngol. Article Google Scholar.
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