Management of iatrogenic parathyroid failure: beyond current BAETS guideline

Abstract

Abstract Introduction Hypocalcaemia is the most common post-operative complication of total thyroidectomy, in 23.5% of cases. The management of acute hypocalcaemia is well described, however there remains a lack of evidence for longer term management of these patients with ongoing parathyroid failure. We show how this could be predicted, prevented, and appropriately managed. Method We performed a systematic review of the literature regarding hypocalcaemia and parathyroid failure following total thyroidectomy. Results Risk factors for the development of hypocalcaemia include: female gender; lower age; Graves’ disease; level VI neck dissection; and poor surgical technique. Biochemical markers predict ongoing hypocalcaemia: calcium < 1.88mmol/L 24 hours after surgery is a significant risk; PTH ≥ 1.6pmol/L is a low risk. Combining calcium levels and PTH at 4 hours post-operatively helps significantly improve the predictive values and patients can be started on treatment as required. Day 5 post-operative repeat PTH and calcium monitors the need for medication. A key moment is 1 month following surgery, when two thirds of hypocalcaemic patients have recovered. Repeated blood tests at this point can help stopping or decreasing medical therapy. Conclusions This research work yields a structured approach to deal with persistent hypocalcaemia into four different categories. It may help discharging patients early from hospital after thyroidectomy and also may avoid long-term supplementation. Supplements can be stopped after one month with repeat calcium and parathyroid checks to recognise those who may require long-term treatment. Close communication between surgeons, endocrinologists, and patients is key.