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Published on: July 14, 2023
4-Hour postoperative PTH level predicts hypocalcemia after thyroidectomy in children
R Elliott Overman1, Lily B Hsieh1, Ram Menon2
1Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
Insights
Four-hour postoperative parathyroid hormone (PTH) levels effectively predict hypocalcemia after pediatric total thyroidectomy. This monitoring reduces unnecessary calcium supplementation and lab tests in children.
Area of Science:
- Pediatric Endocrinology
- Surgical Oncology
- Endocrine Surgery
Background:
- Hypocalcemia is a common complication following pediatric total thyroidectomy.
- Postoperative parathyroid hormone (PTH) monitoring is established in adults for predicting hypocalcemia.
- The utility of 4-hour postoperative PTH in pediatric patients remains under investigation.
Purpose of the Study:
- To evaluate the effectiveness of the 4-hour postoperative intact parathyroid hormone (PTH) level in guiding calcium supplementation decisions in pediatric patients after total thyroidectomy.
Main Methods:
- Retrospective review of pediatric patients (July 2011-July 2018) undergoing total thyroidectomy.
- Intact PTH levels measured 4 hours postoperatively were used to guide calcium supplementation from November 2014 onwards.
- Concurrent monitoring of serum total and ionized calcium levels, with follow-up in endocrine surgery clinic.
Main Results:
- A 4-hour postoperative PTH level below 10 pg/dL demonstrated 81% sensitivity and 91% specificity for identifying hypocalcemia.
- Patients with low 4-hour PTH levels had significantly higher rates of hypocalcemia (72.7%) and symptomatic hypocalcemia (45.5%).
- No patients with normal 4-hour PTH levels developed symptomatic hypocalcemia or required intravenous calcium.
Conclusions:
- The 4-hour postoperative serum PTH level is a reliable biomarker for predicting hypocalcemia in pediatric thyroidectomy patients.
- Utilizing this biomarker can optimize calcium supplementation protocols, reducing unnecessary interventions and monitoring.
- This approach enhances patient care by minimizing iatrogenic complications and healthcare resource utilization.
Background:
Hypocalcemia occurs frequently after a total thyroidectomy in pediatric patients. Four hour postoperative PTH monitoring predicts the need for calcium supplementation in the adult thyroidectomy population. We evaluated the role of the 4 h postoperative PTH level in determining the need for calcium supplementation after thyroidectomy in the pediatric population.
Methods:
This is a retrospective review of children undergoing total thyroidectomy by a single pediatric surgeon from July 2011 through July 2018. Intact PTH obtained four hours postoperatively determined the need for calcium supplementation for patients beginning in November 2014 onward. Serum total calcium levels were monitored concurrently with serum intact PTH levels. Serum calcium levels were followed in our Multispecialty Pediatric Endocrine Surgery clinic within the month following thyroidectomy.
Results:
From July 2011 through July 2018, there were a total of 56 total thyroidectomies at our institution. Prior to November 2014, all pediatric total thyroidectomies received calcium supplementation per our institutional protocol. Based on ionized calcium levels, 26.3% (5/19) of children developed hypocalcemia. From November 2014 to July 2018, 37 pediatric patients required total thyroidectomies. 29.7% (11/37) had low 4-h postoperative PTH levels. 72.7% (8/11) patients with low 4-h postoperative PTH levels had corresponding postoperative day 1 total calcium levels less than 8.5 or ionized calcium levels less than 1.12, and five children (45.5%) developed symptomatic hypocalcemia. 70% (26/37) of children had normal 4-h postop PTH levels, with only 5 (19%) ever developing hypocalcemia. No patients with a normal postop PTH level developed symptomatic hypocalcemia or required IV calcium repletion. A single 4-h postoperative PTH <10 pg/dl for identifying hypocalcemia has a sensitivity of 81% and specificity of 91%, with AUC 0.81.
Conclusion:
The 4-h postoperative serum PTH level can help determine the need for calcium supplementation in pediatric patients undergoing total thyroidectomy, thereby reducing unnecessary calcium supplementation and serial lab draws to monitor for postoperative hypocalcemia.
Level Of Evidence:
Level II.
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