Hypocalcemia as an important differential diagnosis in patients suffering from stridor following thyroidectomy
In our outpatient protocol, we initiate calcitriol therapy at 0.25 μg once or twice a day for moderate, and 0.5 μg once or twice a day for severe hypocalcemia, or if 1-hour postoperative PTH level is less than 15 pg/mL. We recommend rechecking calcium and PTH levels in 2 to 3 days after the initiation of calcitriol therapy and then every 3 days thereafter to avoid an overdose and development of rebound hypercalcemia. A cautionary note to all providers is to be very cautious with administration of calcitriol in combination with calcium in patients with borderline renal function or the elderly. There are multiple reasons why a patient with acute illness may experience hypocalcemia.
Hypocalcemic Crisis: Acute Postoperative and Long-Term Management of Hypocalcemia
Patients often complain of numbness and tingling in their fingertips, toes, and the perioral region. Paresthesias of the extremities may occur, along with fatigue and anxiety. Muscle cramps can be very painful and progress to carpal spasm or synthroid precautions tetany. In extreme cases of hypocalcemia, bronchospasm and laryngospasm with stridor may occur. Muscle symptoms can be so severe as to present with a polymyositis-like picture with elevated muscle isoenzymes. Clinically, neuromuscular irritability can be demonstrated by eliciting Chvostek’s or Trousseau’s signs.
The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%. By optimising postoperative care, this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay. Parathyroid gland surgery may be necessary when Hypocalcemia is caused by issues related to the parathyroid gland. Approximately 40% of patients with chronic kidney disease may experience hypocalcemia. The kidneys play a pivotal role in maintaining calcium balance, and their failure can lead to abnormal calcium and phosphate metabolism, ultimately causing hypocalcemia.
Three recent trials have tested the ability of PTH(1-84) therapy to permit lowering of calcium and calcitriol supplements safely while maintaining serum calcium homeostasis in patients with chronic hypoparathyroidism ( ). Since there was no placebo control group in this study, reports of improved quality of life parameters (122) must be interpreted cautiously. There are many causes of hyperphosphatemia, including increased intake of phosphate, decreased excretion of phosphate or increased translocation of phosphate from tissue breakdown into the extracellular fluid. Renal insufficiency is probably the most common cause of hyperphosphatemia.
A symptom-based algorithm for calcium management after thyroid surgery: a prospective multicenter study
Casr mutations are considered to be second to post-surgical hypoparathyroidism in frequency as a cause of hypoparathyroidism in the adult. During the perioperative period, patients have two sets of blood tests, at 4-hours and day 1 (12-hours) post operation. The first blood test consists of both calcium levels and parathyroid hormone (PTH).
Mutations Affecting the Extracellular Calcium-Sensing Receptor
Prevention of postoperative hypocalcemia starts with preoperative patient counseling. Patients should be taught to recognize early signs and symptoms of hypocalcemia. In addition, the importance of medical adherence and compliance to calcium supplementation postoperatively should be stressed to prevent severe hypocalcemia and its potential for life-threatening symptoms.
- While not answering this question, this study provides more information for surgeons, thyroid experts and patients to use when deciding on the best surgery for this relatively low-risk cancer.
- If the levels are within normal ranges, we stop calcium replacement earlier.
- Furthermore, patients who underwent total thyroidectomy were at the greatest risk of developing post-thyroidectomy hypocalcemia.
- Their presence correlates with disease duration and extent of transfusions.
Rapid release of cellular phosphate may occur causing the tumor lysis syndrome (97). In rhabdomyolysis due to crush injury, hypocalcemia and hyperphosphatemia may occur. In diabetic ketoacidosis, ketone-induced urinary losses of phosphate deplete total body stores, but patients may present with hyperphosphatemia. When the volume shifts during the correction of hyperglycemia and acidosis, the shift of phosphate back into cells can result in mild transient hypophosphatemia. One of the most common causes is vitamin D deficiency, or osteomalacia, which I will talk about in a future podcast.
Patient Education
So, corrected calcium levels are recommended for people with hypoalbuminemia, or low albumin levels. The QI team consisted of a head and neck consultant and two junior doctors. This helped the QI team to identify both areas for improvement and implement change. To encourage stakeholder involvement and engagement, these meetings were repeated as the ‘Plan, Do, Study, Act’ (PDSA) cycle evolved.
Carpal spasm presents as flexion of the wrist and of the metacarpal phalangeal joints, extension of the interphalangeal joints, and abduction of the thumb. Hypocalcemia can present as an asymptomatic laboratory finding or as a severe, life-threatening condition (Table 1). Distinguishing acute from chronic hypocalcemia and asymptomatic from severely symptomatic hypocalcemia is critical for determining appropriate therapy.
Hypoparathyroidism, Sensory Neural Deafness, Renal Dysplasia Syndrome
A healthy lifestyle, including regular exercise and minimal alcohol consumption, positively affects hormonal balance. A baseline audit was conducted to determine the initial guideline compliance. The QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover. Calcitriol and alfacalcidol are active forms of Vitamin D that help the body absorb calcium.
