Inpatient and Outpatient Specialty Care Clinical Pathway for
Calcium Management in Children 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
ioPTH Level | Treatment | Escalation |
---|---|---|
High Risk < 10 pg/mL |
|
|
Intermediate Risk 10-20 pg/mL |
|
|
Low Risk > 20 pg/mL |
|
|
- Medications: Calcium, Calcitriol, Thyroid Hormone Therapy
- Laboratory Studies: Calcium, Phosphorous, PTH
- Appointments: Surgery, ENT, Thyroid Center
Evidence
- Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy
- A Clinical Pathway for the Postoperative Management of Hypocalcemia After Pediatric Thyroidectomy Reduces Blood Draws
- Initial Clinical Experiences Using the Intraoperative Probe-based Parathyroid Autofluorescence Identification System-PTeye During Thyroid and Parathyroid Procedures
- Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery
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