PICU, Inpatient and Outpatient Specialty Care Clinical Pathway for Peri-Operative Management of Hypocalcemia in Children with 22q11.2 Deletion/Duplication

 
 
Preoperative Care
 
 
 
 
Scheduled Elective Procedures

  • Anesthesia APP Provider
  • Endocrine Calcium Emergency Letter in Epic
  • Current Ca treatment
  • Recent Ca level (within 3 mos)
  • Notifies outpatient Endocrinologist of planned procedure
  • Place blood drawing IV for repeating post-op Ca levels
  • Pre-Procedural Endocrine and Genetics Evaluations
    • Scheduling with Endocrine, urgent appointments, children without known history or hypocalcemia
  • Endocrine
  • Orders Ca, albumin if no results within 3 mos
  • Documents peri-operative recommendations in Epic
Inpatient Procedures

  • Hospital Provider Reviews:
    • Endocrine Calcium Emergency Letter in Epic
  • Current Ca Treatment
  • Recent Ca level (within 3 mos)
  • Orders Ca, albumin if no results within 3 mos
  • Consults Endocrine
 
 
 
 
Postoperative Hypocalcemia Treatment and Monitoring Recommendations
Signs and Symptoms of Hypocalcemia
  Monitoring Treatment for Ca < 8.5 mg/dL Escalation
  • High Risk
  • Patient Factors
  • History of hypocalcemia with procedures/illness or baseline requirement for calcium and/or calcitriol supplementation
  • Procedure Factors
  • Longer/more invasive procedures
  • Delayed transition to PO/usual
    enteral intake
  • All
  • Post-op Ca within 1-4 hrs post procedure if procedure lasts ≥ 2 hrs
  • Inpatient
  • Continue Ca monitoring every 4-6 hrs
    • Discontinue if 2 Ca ≥ 8.5 mg/dL more than 8 hrs apart
  • Outpatient
  • Review child’s post-discharge
    • Ca monitoring plan
  • Typically, if Ca normal, check 2-3 days
    post-discharge
  • Labs ordered by primary endocrinologist
  • Consult Endocrine
  • Give
  • Followed by
  • Goal: Start within 4 hrs of surgery
  • Asymptomatic
    • Start at lower end of suggested
      dose ranges
  • Signs/Symptoms of Hypocalcemia
    • Consider escalation
  • Titration
    • Titrate the calcium and/or calcitriol with support of Endocrine consult if there is no improvement in Ca level
  • Intermediate Risk
  • Patient Factors
  • History of mild hypocalcemia with procedures/illness
  • Procedure Factors
  • Longer/more invasive procedures
  • Delayed transition to PO/usual
    enteral intake
  • All
  • No routine post-procedure Ca monitoring
  • Obtain post-procedure Ca if child is not back to baseline (sedated, not taking PO well) within 4 hrs
  • Inpatient
  • Continue Ca monitoring every 4-6 hrs
    • Discontinue if 2 Ca ≥ 8.5 mg/dL more than 8 hrs apart
  • Outpatient
  • Review child’s post-discharge
    • Ca monitoring plan
  • Typically, if Ca normal, check 2-3 days
    post-discharge
  • Labs ordered by primary endocrinologist
  • Consult Endocrine
  • Give
  • Goal: Start within 4 hrs of surgery
  • Asymptomatic
    • Start at lower end of suggested
      dose ranges
  • Signs/Symptoms of Hypocalcemia
    • Consider escalation
  • Low Risk
  • Patient Factors
  • No known history of hypocalcemia
  • Procedure Factors
  • Short procedure with quick post-procedure transition to home feeding regimen