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Surgical Morbidity - postop hypocalcemia.pptx
- 2. Transient Hypocalcemia S/p Total thyroidectomy for a Multinodular Non toxic Goiter Clavien-Dindo II Dr. Sarah Jane Imbong
- 3. DATE INITIALS AGE/SEX PRE-OP DX PROCEDURE POST-OP DX HISTOPATH OUTCOME 01/29/2024 CA 33/F MULTINODULAR GOITER TOTAL THYROIDECTOMY MULTINODULAR GOITER READMITT ED The left thyroid gland is enlarged with a 5.1 x 3.9 x 2.4 cm mixed solid to cystic, isoechoic mass with smooth margins and apparent vascularity on color flow Doppler study seen. No calcifications noted. The right thyroid lobe and isthmus appear homogenous with no focal lesions seen. No calcifications seen. No abnormal areas of increased vascularity on color flow Doppler. Scan of both lateral neck segments were unremarkable. The submandibular glands appears homogenous with no definite cystic nor solid lesions seen. FT4:13.8 TSH:0.62 iCa: 1.131 WBC: 7.7 Hgb: 12.5 Hct: 38.5 INR: 0.96 No family history of thyroid related diseases No previous surgery No known allergic reactions Physical Exam: Mass moves with deglutition, palpable mass noted on the left thyroid gland approx. 4cm x 3cm Movable, non fixed, soft, no lymph adenoapthy noted
- 5. Course in the wards
- 6. Post operative day 1 • S:no hoarseness noted, no peri oral numbness noted, no tingling sensation of the digits, PS: 3/10 post op site, no dyspnea • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 120/70 • HR: 82 • RR:19 • Temp: 36.7 • Head and Neck: no redness, no discharges, no edema, no expanding hematoma noted on the post op site. • Ionized Calcium (6hrs Post op): 1.08
- 7. Post operative day 1 • A: Post operative day 1 • S/P total thyroidectomy • P: IVF to consume • Medications shifted to Oral • Calcium tablets 1 tablet TID • Dressing of wound done • Possible discharge on POD2
- 8. Post operative day 2 • S:no hoarseness noted, no peri oral numbness noted, no tingling sensation of the digits, PS: 2/10 post op site, no dyspnea • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 100/70 • HR: 75 • RR:20 • Temp: 36.9 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, no hematoma noted, no peri-oral numbness, no Chvostek noted
- 9. Post operative day 2 • S:no hoarseness noted, no peri oral numbness noted, no tingling sensation of the digits, PS: 2/10 post op site, no dyspnea • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 100/70 • HR: 75 • RR:20 • Temp: 36.9 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, no hematoma noted, no peri-oral numbness, no Chvostek noted
- 10. Post operative day • A: Post operative day 2 • S/P total thyroidectomy • Post op site seroma • P: Patient is for discharge • Take home medications • Antibiotics x 7 days • Calcium tablets 1 tab 2x a day x 1 week • Follow up at surgery opd after 1 week • Daily dressing of wound • Warm compress over the post op site 10-15 minutes BID
- 11. Post Operative day 3 • Patient was at the emergency Department with complaints of carpopedal spasms involving the upper extremity. • Peri-oral numbness, (+) Chovstek’s, (+) trousseau sign • Ionized calcium: 0.94 mmol/L (1.08) • Mg: 1.40 mg/dl (1.60-2.30) • Albumin: 4.5 g/dL • Potassium: 3.60 mmol/L • Management: • IV line started • O2 supplementation started at 2L/min
- 12. Post Operative day 3 • Management: • IV line started • O2 supplementation started at 2L/min • IV calcium gluconate 10%/ 10ml vial was given slow iv over 10 minutes • Patient was attached to cardiac monitor • 12 leads ECG taken which showed no cardiac dysrhythmia noted • Magnesium correction was started with magnesium 1 gram in 100cc pnss IV infusion to run for 1 hour • Calcium +Vitamin D3 tablet was continued now given 2 tabs 3x a day • For repeat ionized calcium 6 hrs after 1st calcium gluconate was given
- 13. Post Operative day 3 (HOD1) • Management: • Repeat ionized Calcium: 0.89 mmol/L (0.94) • Signs of hypocalcemia: (+) peri-oral numbness, (+) tingling sensation of the digits, (+) tingling sensation of the lower extremities, (+) chovsteks, (-) trousseau sign • Patient was then admitted • Management: IV calcium gluconate was started, calcium gluconate 10% 4 vials (10ml/vial) in 400 cc PNSS to run for 12 hours was started • Repeat ionized calcium levels taken after calcium drip
- 14. Post Operative day 4 (HOD2) • S:no hoarseness noted, (+) peri oral numbness noted, (+) tingling sensation of the digits, • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 120/80 • HR: 89 • RR: 18 • Temp: 36.8 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, no Chvostek noted • (-) trousseau sign
- 15. Post Operative day 4 (HOD2) • A: POD 4, S/P total thyroidectomy • Hypocalcemia • Hypomagnesemia- corrected • P: Oral Calcium +Vit D tablets, 2 tabs BID • Continue Calcitriol 0.25mg/tab BID • Repeat ionized calcium – 1.04 (0.89)
- 16. Post Operative day 5 (HOD3) • S:no hoarseness noted, (+) peri oral numbness noted, (+) tingling sensation of the digits, • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 100/80 • HR: 75 • RR: 19 • Temp: 36.4 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, (+) Chvostek noted • (-) trousseau sign
- 17. Post Operative day 5 (HOD3) • A: POD 5, S/P total thyroidectomy • Hypocalcemia • Hypomagnesemia- corrected • P: 1 dose Calcium gluconate 10% 10ml/vial • Oral Calcium +Vit D tablets, 2 tabs BID • Continue Calcitriol 0.25mg/tab BID • Repeat ionized calcium – 0.94 (6am) (1.04) • Repeat ionized calcium – 0.97 (6pm)
- 18. Post Operative day 6 (HOD4) • S:no hoarseness noted, (-) peri oral numbness noted, (+) tingling sensation of the digits, and lower extremities • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 110/80 • HR: 85 • RR: 20 • Temp: 37.0 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, (-) Chvostek noted • (-) trousseau sign
- 19. Post Operative day 6 (HOD4) • A: POD 5, S/P total thyroidectomy • Hypocalcemia • Hypomagnesemia- corrected • P: Oral Calcium +Vit D tablets, 2 tabs BID • Continue Calcitriol 0.25mg/tab BID • Repeat ionized calcium – 1.04 (6am) (0.97) • Repeat ionized calcium – 0.96 (6pm) • Serum magnesium- 1.8 (N)
- 20. Post Operative day 7 (HOD5) • S:no hoarseness noted, (-) peri oral numbness noted, (+) tingling sensation of the digits, and lower extremities • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 110/80 • HR: 85 • RR: 20 • Temp: 37.0 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, (-) Chvostek noted • (-) trousseau sign
- 21. Post Operative day 7 (HOD5) • A: POD 5, S/P total thyroidectomy • Hypocalcemia • Hypomagnesemia- corrected • P: Oral Calcium +Vit D tablets, 2 tabs BID • Continue Calcitriol 0.25mg/tab BID • Repeat ionized calcium – 1.0 (6am) (0.96)
- 22. Post Operative day 8 (HOD6) • S:no hoarseness noted, (-) peri oral numbness noted, (-) tingling sensation of the digits, and lower extremities • O: Awake, cooperative, follows command, not in distress • Vital signs • : BP: 100/80 • HR: 87 • RR: 20 • Temp: 36.8 • Head and Neck: no discharges noted, minimal swelling was noted on the post op site, (-) Chvostek noted • (-) trousseau sign
- 23. Post Operative day 8 (HOD6) • A: POD 5, S/P total thyroidectomy • Hypocalcemia- resolving • Hypomagnesemia- corrected • P: Oral Calcium +Vit D tablets, 2 tabs BID • Continue Calcitriol 0.25mg/tab BID • Repeat ionized calcium – 1.2 (6am) (1.0) • Patient was discharged, with prescription to continue • Oral Calcium +Vit D tablets, 2 tabs BID • Continue Calcitriol 0.25mg/tab BID
- 25. hypocalcemia Technical Patient Factors Devascularization of the parathyroid Large tumor Inadvertent removal Equipment Energy device Surgeon factor Low volume Resident trainee Pre operative No pre- op Calcium and vit. D supplementation Post operative Management No repeat iCal 24 hrs post op
- 26. Is pre operative calcium supplementation decreases chances of hypocalcemia post total thyroidectomy? YES
- 29. hypocalcemia Technical Patient Factors Devascularization of the parathyroid Large tumor Inadvertent removal Equipment Energy device Surgeon factor Low volume Resident trainee Pre operative No pre- op Calcium and vit. D supplementation Post operative Management No repeat iCal 24 hrs post op
- 31. Terms • Hypocalcemia is a total serum calcium level that is less than the lower limit of the center-specific reference range • Clinical hypoPT is defined as biochemical hypoPT that is accompanied by symptoms and/or signs of hypocalcemia. • Transient or temporary hypoPT is defined as occurring for less than six months after surgery, while permanent hypoPT continues beyond six months after surgery
- 32. Mechanism underlying hypocalcemia post operatively 1. disruption of parathyroid arterial supply or venous drainage 2. mechanical injury 3. thermal or electrical injury 4. intentional or inadvertent partial or complete removal
- 33. Signs and Symptoms • neuromuscular excitability and cardiac electrical instability • Muscle stiffness, cramps, and spasms • Neuropsychiatric symptoms • positive Chvostek sign • positive Trousseau sign • Cardiovascular prolonged QT interval, V-tachs, V Fib
- 35. Risk Factors • Bilateral (simultaneous or sequential) thyroid procedures • Central neck dissection—prophylactic or therapeutic • Substernal goiter • Low-volume thyroid surgeon • Simultaneous thyroidectomy and parathyroidectomy • Prior central neck surgery
- 36. Preoperative Vitamin D Deficiency • Vitamin D increases the absorption of calcium from the intestinal tract • Vitamin D deficiency can be severe (below the lowest recordable level, <10 ng/mL), moderate (10 to <20 ng/mL), or mild (20–30 ng/mL). • The Food and Drug Administration (FDA) approved regimen is 50,000 IU of vitamin D3 (cholecalciferol) weekly or 6000 IU daily for eight weeks
- 37. Surgical Techniques and Tools • Preservation of all four parathyroid glands during total thyroidectomy is a critically important operative goal Superior - near the posterior aspect of the upper and middle lobe (80%) • Inferior - w/in 1 cm from a point where the ITA and RLN cross • Intrathyroidal glands (0.5-3%
- 39. Surgical Techniques and Tools Energy Device -generate a zone of collateral thermal spread within the tissues - optimal 3–5 mm distance of separation
- 40. Biochemical testing: perioperative Calcium and PTH • CALCIUM • Obtaining calcium levels 6 hrs ,12 hrs and 24 hrs post operatively check for the trend • Increasing deemed safe for hospital discharge with or without calcium supplementation • Decreasing observation for another 24 hrs and correction of calcium is advised • PTH is a hormone secreted by the parathyroid gland to regulate calcium levels • Half life 2-4 minutes
- 42. • ATA Surgical Affairs Committee that a PTH value >15 pg/mL measured in adults at >20 minutes following thyroidectomy would obviate the need for intensive serum calcium monitoring and/or calcium supplementation. • A postoperative PTH value of <15pg/ml would suggest an increased risk for acute hypoPT that might prompt preemptive prescribing of oral calcium and calcitriol and/or serial serum calcium measurements until calcium stability has been confirmed Biochemical testing: perioperative Calcium and PTH
- 43. Post Operative Management • Patients whose PTH is <15pg/ml, serum calcium <8.5mg/dl, ionized calcium <1.1mmol/l should be considered for post operative oral calcium supplementation • Regimen 400-1200mg/ day elemental calcium ((1–3 g of calcium carbonate) or calcium citrate (2000–6000 mg per day) • Symptomatic hypocalcemia add calcitriol, typically 0.25–0.5 lg twice daily • Serum magensium low magnesium supplementation with 400 mg of magnesium oxide once or twice daily
- 44. Post Operative Management • Calcium given by i.v. bolus (1–2 g of calcium gluconate [93 mg elemental calcium in one vial of calcium gluconate] in 50 mL of 5% dextrose infused over 20 min)
- 45. hypocalcemia Technical Patient Factors Devascularization of the parathyroid Large tumor Inadvertent removal Equipment Energy device Surgeon factor Low volume Resident trainee Pre operative No pre- op Calcium and vit. D supplementation Post operative Management No repeat iCal 24 hrs post op
- 46. Recommendation
- 47. Recommendation • Conduct surgery so as to avoid removal or devascularization of parathyroid tissue • Check Specimen, autotransplant devascularized or inadvertently removed normal parathyroid glands • Either treat at-risk patients empirically with calcium, or measure calcium and/or PTH in the immediate postoperative period and treat according to evidence-based protocols • Titrate calcium with or without calcitriol to maintain eucalcemia, and wean calcium and/or calcitriol when appropriate
- 48. Recommendation • Communication between providers is critical, since hypoPT may be prolonged and can negatively affect multiple organ systems • Inability to achieve independence from calcium by six months indicates permanent hypoPT • Avoiding hypoPT is much less costly than treating hypoPT
- 49. END
Editor's Notes
- 4 years noted slowly growing mass No fam hx No choking sensation No hoarseness noted
- Hypocalcemia: Low levels of calcium in the blood affect the excitability threshold of nerve and muscle cells. Calcium ions play a crucial role in neuromuscular function, including muscle contraction and nerve impulse transmission. Reduced levels of calcium result in increased excitability of nerve membranes, leading to spontaneous depolarization and enhanced sensitivity to stimuli. In this context, when the blood pressure cuff is inflated above systolic pressure, it induces ischemia in the underlying nerves and muscles of the forearm. This ischemic insult exacerbates the hyperexcitable state of nerves and muscles, leading to the characteristic carpal spasm observed in the Trousseau sign. Nerve Hyperexcitability: Muscle Hyperexcitability: Similarly, skeletal muscle cells become hyperexcitable in hypocalcemia. This increased excitability can manifest as muscle cramps, spasms, or tetany. Vasodilation: In addition to neuromuscular effects, hypocalcemia can also lead to vasodilation, which reduces vascular tone and blood pressure. When the blood pressure cuff is inflated above systolic pressure, it further compresses the blood vessels in the arm, leading to reduced blood flow. This ischemic condition exacerbates the excitability of nerves and muscles. flexion of the wrist, thumb, and metacarpophalangeal joints and hyperextension of the fingers, upon brachial artery occlusion by inflation of a blood pressure cuff above systolic blood pressure) the Chvostek sign is thought to result from increased neuromuscular irritability due to low levels of ionized calcium in the blood, which is characteristic of hypocalcemia. Calcium ions play a crucial role in stabilizing cell membranes and regulating neuromuscular excitability. When calcium levels are low, there is increased excitability of nerve and muscle cells, leading to spontaneous depolarization and exaggerated responses to stimuli. Tap-induced activation of the facial nerve in hypocalcemic individuals can trigger this hyperexcitability, resulting in the observed facial muscle twitch.
- Assessment and analysis- discussion of possible causes of the complication: a. Error analysis- what happened? - describe the sequence of events leading to the adverse outcome
- AS EARLY AS Published online 2019 Feb 22. The aim of this randomized controlled trial was to ascertain the usefulness of routine pre- and post-operative calcium and Vitamin D supplementation in prevention of hypocalcemia after TT. 60 pts randomized into 2 groups Group 1 received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mcg every 6 h) 7 days before and 7 days after the surgery; Group 2 did not receive supplementation Results: Twelve patients from Group 2 developed symptomatic hypocalcemia (P < 0.01) Twenty-four hours postoperative serum calcium level was significantly associated with grade of goiter, preoperative calcium, and nature of thyroid disease (benign or malignant).
- Published online 2022 Aug 26. Comparative studies among protocols for the management of post-total thyroidectomy (TT) hypocalcemia are lacking. We compared the effectiveness of PTH-driven selective supplementation (PD-SS) and routine calcium and calcitriol supplementation with preoperative calcitriol administration in preventing symptomatic hypocalcemia (SH) and readmission. Three-hundred consecutive patients undergoing TT were assigned to 3 groups: the PD-SS group, the high-dose routine supplementation (HD-RS) group and the low-dose routine supplementation (LD-RS) group.
- Assessment and analysis- discussion of possible causes of the complication: a. Error analysis- what happened? - describe the sequence of events leading to the adverse outcome
- Transient serum calcium values outside the normal reference range may reflect dynamic changes in electrolytes and state of hydration rather than true hypocalcemia. Hypocalcemia may occur independent of hypoPT, but untreated hypoPT always leads to hypocalcemia, even though time lag can range from hours to days.
- Normal parathyroid function requires a rich blood supply; Parathyroid blood supply is both delicate and complex, and requires close attention during thyroidectomy to ensure its preservation. While the inferior thyroid artery is typically the dominant blood vessel that supplies the parathyroid glands, laser Doppler flowmetry has shown that the superior thyroid artery and vessels within the thymo-thyroid cord (ligament) can gives off supply to the parathyroid The use of energy devices for vessel sealing during thyroidectomy is another relevant surgical technical factor. These energy devices generate a zone of collateral thermal spread within the tissues, and necessitate an optimal 3–5 mm distance of separation between the instrument and the parathyroid gland in order to avoid thermal injury Calcium is essential for various physiological functions in the body, including muscle contraction, nerve function, blood clotting, and bone health. The parathyroid glands, typically four small glands located behind the thyroid gland in the neck, play a central role in regulating calcium levels. They secrete parathyroid hormone (PTH) in response to changes in blood calcium levels. he parathyroid glands contain calcium-sensing receptors that monitor the concentration of calcium in the blood. When blood calcium levels decrease, these receptors detect the change and stimulate the release of PTH from the parathyroid glands. PTH acts on several target organs to increase blood calcium levels: Bone: PTH stimulates the release of calcium from bone stores into the bloodstream through a process called bone resorption. Kidneys: PTH enhances the reabsorption of calcium from the kidneys, reducing urinary calcium excretion. Intestines: PTH indirectly increases intestinal absorption of calcium by promoting the production of active vitamin D (calcitriol), which facilitates calcium absorption from the gastrointestinal tract
- Hypocalcemia causes neuromuscular excitability and cardiac electrical instability due to a reduced nerve and muscle cell depolarization threshold. I ts most common early symptoms are paresthesias, or numbness and tingling, of the perioral region and the fingertips. Muscle stiffness, cramps, and spasms are also common. Neuropsychiatric symptoms include confusion, anger, depression, lightheadedness, and irritability. More sustained muscle contraction may lead to laryngospasm, and more severe neural excitability may lead to seizures. Classic bedside findings are a positive Chvostek sign (facial muscle twitching upon tapping the preauricular region over the facial nerve; present at baseline in up to 25% of people) flexion of the wrist, thumb, and metacarpophalangeal joints and hyperextension of the fingers, upon brachial artery occlusion by inflation of a blood pressure cuff above systolic blood pressure) A This occludes arterial blood flow to the forearm, leading to ischemia (reduced blood supply) to the muscles and nerves in the arm. BP cuff is inflated 20mmgh above the SBP, arterial blood flow is occluded 3-5 minutes Flexion of the wrist Flexion of the MCP joints Extension of the IP joints Adduction of the thumb/ fingers Cardiovascular signs observed with progressive hypocalcemia include prolongation of the QT interval that can result in torsades de pointes, a form of ventricular tachycardia that may degenerate into ventricular fibrillation.
- Hypocalcemia: Low levels of calcium in the blood affect the excitability threshold of nerve and muscle cells. Calcium ions play a crucial role in neuromuscular function, including muscle contraction and nerve impulse transmission. Reduced levels of calcium result in increased excitability of nerve membranes, leading to spontaneous depolarization and enhanced sensitivity to stimuli. In this context, when the blood pressure cuff is inflated above systolic pressure, it induces ischemia in the underlying nerves and muscles of the forearm. This ischemic insult exacerbates the hyperexcitable state of nerves and muscles, leading to the characteristic carpal spasm observed in the Trousseau sign. Nerve Hyperexcitability: Muscle Hyperexcitability: Similarly, skeletal muscle cells become hyperexcitable in hypocalcemia. This increased excitability can manifest as muscle cramps, spasms, or tetany. Vasodilation: In addition to neuromuscular effects, hypocalcemia can also lead to vasodilation, which reduces vascular tone and blood pressure. When the blood pressure cuff is inflated above systolic pressure, it further compresses the blood vessels in the arm, leading to reduced blood flow. This ischemic condition exacerbates the excitability of nerves and muscles.
- HypoPT may follow any simultaneous or staged bilateral central neck operation A prior partial thyroid operation creates a potentially increased risk of hypoPT during completion thyroidectomy, due to unknown status (presence or viability) of the parathyroid glands in the previously operated neck.
- Vitamin D plays a crucial role in promoting the absorption of calcium from the gastrointestinal tract. In the small intestine, active vitamin D (calcitriol) stimulates the expression of proteins that facilitate the absorption of dietary calcium across the intestinal lining into the bloodstream. Without sufficient vitamin D, calcium absorption efficiency decreases, leading to lower calcium levels in the blood. Vitamin D helps regulate blood calcium levels by promoting calcium absorption from the intestines and facilitating calcium reabsorption by the kidneys. When blood calcium levels drop, parathyroid hormone (PTH) secretion increases, which stimulates the production of active vitamin D in the kidneys. This, in turn, enhances calcium absorption from the gut and reduces urinary calcium excretion, thereby raising blood calcium levels
- Preservation of all four parathyroid glands during total thyroidectomy is a critically important operative goal, but this objective is not always attainable due to the extent of thyroid disease, plus variations in the anatomical locations and blood supply of the parathyroid glands. Avoiding parathyroid damage first requires that the surgeon is able to recognize parathyroid tissue accurately. The parathyroid glands are difficult to distinguish from other cervical tissues because of their small size and similar coloration compared to thyroid, fat, and lymph nodes. Recent promise for improved parathyroid identification has arisen through the intraoperative stimulation of parathyroid tissue fluorescence in the presence of a contrast agent or photosensitizer (indocyanine green, amino levulinic acid hydrochloride [5-ALA], methylene blue) and detection with near-infrared fluorescence imaging
- Recent promise for improved parathyroid identification has arisen through the intraoperative stimulation of parathyroid tissue fluorescence in the presence of a contrast agent or photosensitizer (indocyanine green, amino levulinic acid hydrochloride [5-ALA], methylene blue) and detection with near-infrared fluorescence imaging Location: Parathyroid glands are typically located adjacent to or embedded within the thyroid gland in the neck. In contrast, fat tissue may be present in various locations throughout the body but is not typically found within or directly adjacent to the thyroid gland. Texture: Parathyroid tissue tends to be firmer and more glandular in texture compared to fat tissue, which is softer and more pliable. This difference in texture can sometimes be appreciated during surgical procedures or imaging studies. Color: Parathyroid tissue may have a slightly different color compared to surrounding structures. While this can vary, parathyroid tissue is often described as pale yellowish-brown. Fat tissue may appear more yellow in color due to the presence of lipids.. n general, fat tissue is less dense than water and will float when placed in water. On the other hand, parathyroid tissue, being denser and composed primarily of glandular cells, typically sinks in water. This principle can sometimes be utilized in surgical settings or during certain procedures to help differentiate between tissues. However, it's important to note that this method alone may not be definitive, and other characteristics such as texture, color, and histological features should also be considered for accurate identification of tissues.
- The use of energy devices for vessel sealing during thyroidectomy is another relevant surgical technical factor. These energy devices generate a zone of collateral thermal spread within the tissues, and necessitate an optimal 3–5 mm distance of separation between the instrument and the parathyroid gland in order to avoid thermal injury Location: Parathyroid glands are typically located adjacent to or embedded within the thyroid gland in the neck. In contrast, fat tissue may be present in various locations throughout the body but is not typically found within or directly adjacent to the thyroid gland. Texture: Parathyroid tissue tends to be firmer and more glandular in texture compared to fat tissue, which is softer and more pliable. This difference in texture can sometimes be appreciated during surgical procedures or imaging studies. Color: Parathyroid tissue may have a slightly different color compared to surrounding structures. While this can vary, parathyroid tissue is often described as pale yellowish-brown. Fat tissue may appear more yellow in color due to the presence of lipids.. n general, fat tissue is less dense than water and will float when placed in water. On the other hand, parathyroid tissue, being denser and composed primarily of glandular cells, typically sinks in water. This principle can sometimes be utilized in surgical settings or during certain procedures to help differentiate between tissues. However, it's important to note that this method alone may not be definitive, and other characteristics such as texture, color, and histological features should also be considered for accurate identification of tissues. hyroid cancer surgery has an increased risk of hypoPT when a central lymph node dissection is performed. The superior parathyroid glands are at lower risk of injury or inadvertent removal than the inferior parathyroid glands, since most of the central neck lymph node metastases are generally located in the more inferior paratracheal and pretracheal areas. Sometimes, a small inferior parathyroid vein may be seen to course lateral and anterior to the carotid artery.
- The ability to predict the occurrence of transient hypoPT, by subjective surgeon assessment during operation, is highly variable Objective serial measurement of serum calcium levels has traditionally been used to stratify for risk of symptomatic hypocalcemia development during the postoperative period, and to determine the need for oral calcium and calcitriol administration. After thyroidectomy, the absolute value of serum calcium levels, as well as the trend and slope or rate of change of these values, have also been employed to predict hypoPT fter thyroidectomy, the absolute value of serum calcium levels, as well as the trend and slope or rate of change of these values, have also been employed to predict hypoPT (56–59), but this approach requires sufficient time to observe such a trend. In one study, serum calcium levels were measured at 6 and 12 hours after total thyroidectomy, and patients with a positive serum calcium slope (rise in level) were deemed safe for hospital discharge with or without calcium supplementation (56). For patients with a non-positive slope but with serum calcium levels ≥8 mg/dL, discharge with calcium supplementation was also found to be safe. Because trending calcium often requires sampling over a 12- to 24-hour or longer time period, and because postoperative calcium levels may be confounded by prophylactic calcium and calcitriol administration or by low preoperative vitamin D levels, many groups have examined the utility of measuring intraoperative or postoperative intact PTH levels drawn at various time points in the early post-thyroidectomy period
- Because trending calcium often requires sampling over a 12- to 24-hour or longer time period, and because postoperative calcium levels may be confounded by prophylactic calcium and calcitriol administration or by low preoperative vitamin D levels, many groups have examined the utility of measuring intraoperative or postoperative intact PTH levels drawn at various time points in the early post-thyroidectomy period The timing of PTH measurements in published studies has ranged from 10 minutes to 24 hours post thyroidectomy. Thus, the earliest opportunity to predict hypoPT reliably is through measurement of serum PTH level either at the conclusion of or immediately following surgery. A PTH level <15pg/ml is predictive of impending hypocalcemia he half-life of parathyroid hormone (PTH) in the bloodstream is relatively short, typically around 2 to 4 minutes. This means that half of the circulating PTH will be cleared from the bloodstream within this time frame. After secretion from the parathyroid glands, PTH is rapidly metabolized and cleared by the liver and kidneys. The exact clearance mechanisms and pathways for PTH metabolism involve degradation by enzymes and excretion through the urine. Because of its short half-life, PTH levels in the bloodstream can fluctuate rapidly in response to changes in calcium levels and other factors, allowing for rapid adjustments in calcium homeostasis. This dynamic regulation is crucial for maintaining calcium balance and responding to physiological needs.
- Development of acute hypocalcemia after thyroid surgery lags behind the decline in the serum PTH level, and the patient may have been discharged from the hospital prior to their serum calcium having reached a nadir, which may occur 24–72 hours after thyroidectomy. Therefore, it is important to anticipate the possibility of progressive hypocalcemia, to educate patients about its possible development and steps they should take to avoid and treat it, and to institute measures that both prevent and correct hypocalcemia in the postoperative period. Calcium carbonate (40% elemental calcium) and calcium citrate (21% elemental calcium) are the most common calcium salts and should be taken with meals. Hypomagnesemia (low magnesium levels) can impair PTH secretion and activity, leading to reduced stimulation of calcium release from bone and decreased renal reabsorption of calcium. This can contribute to hypocalcemia. Magnesium levels can affect the sensitivity of parathyroid glands to changes in blood calcium levels. Hypomagnesemia may reduce the responsiveness of parathyroid glands to low calcium levels, leading to inadequate PTH secretion and contributing to hypocalcemia. Magnesium is involved in the metabolism and activation of vitamin D, which plays a crucial role in calcium absorption from the intestines. Hypomagnesemia can impair the conversion of vitamin D to its active form (calcitriol) in the kidneys, reducing intestinal calcium absorption and contributing to hypocalcemia.
- Assessment and analysis- discussion of possible causes of the complication: a. Error analysis- what happened? - describe the sequence of events leading to the adverse outcome
- Knowledge of the causes and effects of hypoPT is essential for its prevention and optimal management. A summary of key recommendations is provided in Table 4. I ndividual surgeons should strive to recognize their own rates of hypoPT and minimize this complication through the measures reviewed. Thoughtful preoperative assessment, meticulous intraoperative surgical technique with potential use of technical adjuncts (especially PTH testing), and prompt diagnosis and judicious treatment should minimize or eliminate the risks and negative consequences of hypoPT.
- Knowledge of the causes and effects of hypoPT is essential for its prevention and optimal management. A summary of key recommendations is provided in Table 4. I ndividual surgeons should strive to recognize their own rates of hypoPT and minimize this complication through the measures reviewed. Thoughtful preoperative assessment, meticulous intraoperative surgical technique with potential use of technical adjuncts (especially PTH testing), and prompt diagnosis and judicious treatment should minimize or eliminate the risks and negative consequences of hypoPT.