Thyroidectomy Calcium Management Clinical Pathway — Inpatient and Outpatient Specialty Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Child Undergoing Total Thyroidectomy

Preoperative Care
- Normalize thyroid hormone levels
- Optimize vitamin D status
- Review home medications to determine continuation of therapy
- Notify lab to anticipate need for Intraoperative parathyroid hormone (ioPTH) levels

Intraoperative Care
Place blood drawing IV
Obtain baseline laboratory studies with induction
- Calcium, phosphorus, magnesium
- Sampling Times of ioPTH Assay
  - 20 mins after induction
  - Once thyroid is removed
  - After central neck dissection complete
    (if indicated/performed)
  - At time of closure

Postoperative Treatment
- Begin timely calcium/calcitriol supplementation based on ioPTH levels
- Liothyronine (L-T3) not formulary; OK to start after discharge
Postoperative Monitoring
- Obtain calcium and phosphorus levels q6hr, more frequent as clinically indicated
- Consider PTH level if symptomatic hypocalcemia or calcium < 8 mg/dL
- If calcium < 8 mg/dL, obtain albumin level
- Monitor for Symptoms of Hypo/Hypercalcemia
  - If symptoms present, consider obtaining EKG

Normal Lab Levels by Age

Calcium, phosphorus, magnesium

Postoperative Treatment Recommendation for Calcium/Calcitriol Based on ioPTH Levels and Risk of Hypocalcemia
Aim to Start within 6 hrs of Surgery
ioPTH Level	Treatment	Escalation
High Risk < 10 pg/mL	Calcium and Calcitriol Treatment Give IV Calcitriol in the OR/recovery room If IV calcitriol is not available, IV Paricalcitol can be used Followed by Oral Calcitriol and Oral Calcium Carbonate As soon as able to tolerate PO Goal: Start within 6 hrs of surgery Contact Hospital Provider if delay > 6 hrs Asymptomatic children – start at lower end of suggested dose ranges Titration Titrate the calcium and/or calcitriol based on Endocrine recommendations if there is no improvement in calcium level	Consult Endocrine Consider: IV calcium if child has symptomatic hypocalcemia Transfer to ICU
Intermediate Risk 10-20 pg/mL	Calcium Treatment Give Oral Calcium Carbonate Goal: Start within 6 hrs of surgery Contact Hospital Provider if delay > 6 hrs Asymptomatic children – start at lower end of suggested dose ranges Titration Titrate the calcium and/or calcitriol if there is no improvement in calcium level	Contact Endocrine for: Low calcium < 8 mg/dL An elevated phosphorus > 5.5 mg/dL, supports the diagnosis of hypoparathyroidism Consider: Increasing PO calcium carbonate and Starting Oral Calcitriol
Low Risk > 20 pg/mL	Calcium Treatment If normal calcium and phosphorus, calcium treatment not needed	Contact Endocrine for: Low calcium < 8 mg/dL An elevated phosphorus > 5.5 mg/dL, supports the diagnosis of hypoparathyroidism Consider: Starting PO calcium carbonate

Discharge Criteria, Medications, Laboratory Monitoring
and Follow-up Recommendations

Medications: Calcium, Calcitriol, Thyroid Hormone Therapy
Laboratory Studies: Calcium, Phosphorous, PTH
Appointments: Surgery, ENT, Thyroid Center

Posted: March 2019
Last Revised: July 2024

Authors:
- Bauer, A. MD;
- Kivel, C. CRNP;
- Giordano, T. DNP;
- Smith, T. CRNP;
- Drill, A. CRNP;
- Gonzales, S. CRNP;
- Zook, J. PharmD

Editors: Clinical Pathways Team

Evidence

Related Programs

Pediatric Thyroid Center

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Inpatient and Outpatient Specialty Care Clinical Pathway for Calcium Management in Children Undergoing Total Thyroidectomy

Evidence

Related Programs

Inpatient and Outpatient Specialty Care Clinical Pathway for
Calcium Management in Children Undergoing Total Thyroidectomy