A clinical pathway for the postoperative management of hypocalcemia after pediatric thyroidectomy reduces blood draws

Patel, Neha A.; Bly, Randall A.; Adams, Seth; Carlin, Kristen; Parikh, Sanjay R.; Dahl, John P.; Manning, Scott C.

doi:10.1016/j.ijporl.2017.12.011

Cited by 32 publications

(23 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…In contrast, low risk patients (ioPTH > 20) are far less likely to have prolonged recovery times. The cut-off levels for the ioPTH tertiles in the CHOP clinical practice guideline used to define the risk of postoperative hypocalcemia are associated with a reduced incidence of symptomatic hypocalcemia (7) and supported by several recent studies showing an increased risk of postoperative hypoparathyroidism for ioPTH <11 pg/ml (31, 35), and a lower risk for ioPTH > 16 pg/ml (24).…”

Section: Discussionmentioning

confidence: 99%

“…Monitoring ioPTH at multiple timepoints provides the surgeon the awareness of a decline in ioPTH levels, affording an opportunity for early administration of calcitriol intraoperatively, and allows for close examination of the resected specimen for parathyroid tissue that may be salvaged via autotransplantation (20–22). The use of surgical monitoring strategies, ioPTH in particular, has primarily been studied in adults with limited data in children (23, 24).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy

et al. 2019

View full text Add to dashboard Cite

Background: Hypoparathyroidism is one of the most common complications for patients undergoing total thyroidectomy. Our study's primary objective was to assess if intraoperative PTH levels correlate with parathyroid gland function recovery time in pediatric patients following total thyroidectomy.Methods: Retrospective review of pediatric patients who underwent thyroid surgery at CHOP for demographics and laboratory test values (calcium, phosphorus, and parathyroid hormone). We defined Time of Recovery (TOR) as the time difference from first intra-operative parathyroid hormone level (ioPTH) timepoint until normalization of PTH (> 10 pg/mL) post-thyroidectomy. Calcium and vitamin D supplements were weaned following normalization of calcium and phosphorous levels postoperatively. Patients were excluded if they lacked three intraoperative PTH timepoints or were missing postoperative follow-up PTH data.Results: 65 patients (54 female), median age 15 (range 5–23 years), underwent thyroid surgery and met study inclusion criteria. The correlations of 2nd and 3rd ioPTHs with TOR were statistically significant (p < 0.05): the lower the ioPTH, the greater the recovery time. Stratifying patients into high-risk (2nd ioPTH ≤ 10 pg/mL), moderate-risk (2nd ioPTH between 10 and 20 pg/mL), and low-risk (2nd ioPTH ≥ 20 pg/mL) tertiles, the TOR decreased by orders of magnitudes from an average of 43.13 ± 76.00 to 6.10 ± 17.44 to 1.85 ± 6.20 days. These differences were statistically significant (p < 0.05).Conclusions: Our study results confirm the usefulness of intraoperative PTH levels to predict pediatric patient recovery post-surgery and provides useful anticipatory guidance to optimize timing and frequency of postoperative laboratory surveillance.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy

et al. 2019

View full text Add to dashboard Cite

show abstract

“…Long-term follow-up visits can proceed expectantly. [44][45][46] 3.15 | Statement 5: Preoperative laryngeal examination, preferably by direct visualization (flexible fiberoptic laryngoscopy), is required for surgical planning. Committee consensus: strongly agree (8.6)…”

Section: Laboratory Evaluation and Patient Managementmentioning

confidence: 99%

“…About 6 months after surgery, thyroid bed US with lymph node mapping should be obtained. Long‐term follow‐up visits can proceed expectantly 44‐46 …”

Section: Part I: Pediatric Thyroid Surgery Fundamentalsmentioning

confidence: 99%

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

et al. 2021

View full text Add to dashboard Cite

Objectives: To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children. Methods: A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.). Results: Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus. Conclusion: Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

show abstract

“…Management of hypocalcemia after total thyroidectomy can be challenging, and no consensus guidelines have been developed. There is a relative paucity of literature pertaining to management of post-operative hypocalcemia following TT in pediatric patients, though some studies have emerged in recent years [1,4,5].…”

Section: Introductionmentioning

confidence: 99%

A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy

Gonsalves

Jamshidi

Newbern

et al. 2020

Journal of Pediatric Endocrinology and Metabolism

View full text Add to dashboard Cite

ObjectivesHypocalcemia following total thyroidectomy (TT) is relatively common. It may result in significant morbidity, prolonged hospital stay, and increased costs. Treatment with intravenous (IV) calcium gluconate may also carry significant risks. In pediatrics, management consensus guidelines are lacking.MethodsAt Phoenix Children’s Hospital, a team of pediatric endocrinologists, surgeons and otolaryngologists developed a clinical pathway for patients undergoing TT. It was a Quality Improvement (QI) project with the primary aim of decreasing IV calcium gluconate use from a baseline of 68% to less than 40% over 15 months. Secondary aims included reducing hypocalcemia and length of hospitalization. Interventions included sending weekly pathway reminder emails, starting pre-operative calcium, and pathway implementation into the electronic health record.ResultsTwenty-seven patients underwent TT over 15 months. IV calcium gluconate use dropped to 48%. Hypocalcemia and length of hospitalization were 96% and 52.7 h (range 21.1–115.7) respectively. Pathway adherence improved after targeted interventions. Eleven (73%) of the 15 patients whose post-operative parathyroid hormone (PTH) nadir was below 15 pg/mL required IV calcium gluconate vs. two (17%) out of 12 with levels above this threshold.ConclusionsStandardizing care allowed for objective outcome analysis. We learned that post-operative serum PTH level was the main risk factor for requiring IV calcium gluconate. Implementing the pathway as a QI project allows for revisions based on outcomes, ultimately resulting in a pathway that best utilizes our infrastructure to optimize care. Other pediatric institutions may face similar challenges and can potentially learn from our experience.

show abstract

A clinical pathway for the postoperative management of hypocalcemia after pediatric thyroidectomy reduces blood draws

Cited by 32 publications

References 16 publications

Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy

Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy

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

A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy

Contact Info

Product

Resources

About