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
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
  • 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
Intermediate Risk
10-20 pg/mL
  • Calcium Treatment
  • Give
  • 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
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
  • Medications: Calcium, Calcitriol, Thyroid Hormone Therapy
  • Laboratory Studies: Calcium, Phosphorous, PTH
  • Appointments: Surgery, ENT, Thyroid Center
Posted: March 2019
Last Revised: July 2024
Editors: Clinical Pathways Team