Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 4  |  Page : 629-631

The role of intraoperative calcium injection for prevention of postoperative hypocalcaemia after total thyroidectomy


1 Department of Surgery, Shebin El-Kom Teaching Hospital, Shebin El-Kom, Menoufiya, Egypt
2 Department of Surgery, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
3 Department of Internal Medicine, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt

Date of Submission24-Apr-2014
Date of Acceptance04-Aug-2014
Date of Web Publication22-Jan-2015

Correspondence Address:
Amr T Hafez
Department of Surgery, Shebin El-Kom Teaching Hospital, Shebin El-Kom, Menoufiya
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.149626

Rights and Permissions
  Abstract 

Objective
The aim of this study was to evaluate the possible role of intraoperative intravenous calcium injection in avoidance of unexplained postoperative hypocalcaemia.
Background
Thyroid surgery has always been the most common endocrine surgical operation. Total thyroidectomy is generally reserved for patients with thyroid malignancy, toxic thyroid, clinically significant goiter and less commonly for thyroiditis. The complications include recurrent laryngeal nerve injury, external branch of superior laryngeal nerve injury, neck hematoma, and hypocalcaemia. Post-thyroidectomy hypocalcaemia can occur in about 9.5-15.4% of the patients. The prevention of hypocalcaemia is the main concern, as some patients may experience hypocalcaemia despite preservation of the parathyroid glands during surgery.
Patients and methods
This prospective study on 40 consecutive patients was conducted from March 2011 to January 2013. The patients were randomly divided into two groups: group I (20 patients) received intraoperative intravenous 10 ml of calcium gluconate containing 500 mg of calcium and group II (20 patients) received no injection. Serum calcium level was measured for all patients preoperatively, 6 h and 5 days postoperatively.
Results
The incidence of postoperative hypocalcaemia was lower in group I than in group II (40 and 65%, respectively); in addition, 35% of the patients in group I suffered from perioral numbness, tingling, and positive Chvostek's sign compared with 50% in group II. In all, 5% of the patients in group I suffered from tetany compared with 15% in group II. Serum calcium levels on the first postoperative day in group I patients were significantly higher than those in group II patients, with mean range of 8.1 ± 0.3 in group I and mean range of 7.8 ± 0.4 in group II.
Conclusion
The prophylactic intravenous injection of calcium gluconate during total thyroidectomy is effective in minimizing risk for postoperative symptomatic hypocalcaemia.

Keywords: Hypocalcaemia, prediction, prevention, total thyroidectomy


How to cite this article:
Hafez AT, El-Shakhs SA, El-Najjar MM, El-Gammal AS, Abdel-Aziz TF. The role of intraoperative calcium injection for prevention of postoperative hypocalcaemia after total thyroidectomy. Menoufia Med J 2014;27:629-31

How to cite this URL:
Hafez AT, El-Shakhs SA, El-Najjar MM, El-Gammal AS, Abdel-Aziz TF. The role of intraoperative calcium injection for prevention of postoperative hypocalcaemia after total thyroidectomy. Menoufia Med J [serial online] 2014 [cited 2020 Apr 7];27:629-31. Available from: http://www.mmj.eg.net/text.asp?2014/27/4/629/149626


  Introduction Top


Hypocalcaemia is a well-recognized complication after total thyroidectomy. Postoperative hypocalcaemia was defined as either symptomatic or laboratory; the laboratory was defined as total calcium concentrations less than 8 mg/dl, even if recorded only in a single measurement either during the hospital stay or at any time after discharge [1]. In most cases, post-thyroidectomy hypocalcaemia is temporary but may take several months to resolve. The cutoff time between a temporary and permanent hypocalcaemia is 6 months [2]. Hypocalcaemia has been reported to occur in 9.5-15.4% of patients and symptomatic hypocalcaemia occurs in 1.7-10.3% [3]. Despite being self-limited in most patients, symptomatic hypocalcaemia is of particular concern because of a delay in its manifestation and the consequent need for prolonged patient hospitalization or readmission. The cause of postoperative hypocalcaemia is multifactorial [4]. One of the common causes of hypocalcaemia is inadvertent removal of parathyroid glands or vascular compromise to the parathyroid glands after thyroidectomy [5]. It is estimated that one normal gland is sufficient for maintaining parathyroid hormone levels and serum calcium homeostasis. The careful inspection of the thyroid specimen intraoperatively allowed reimplantation of inadvertently removed parathyroid glands during thyroidectomy [6]. There are multiple factors that predict postoperative hypocalcaemia, and serum calcium level assessment is the most important predictor - 'the assessment of the decrease in calcium levels postoperatively compared with the immediate preoperative levels' - of hypocalcaemia in patients undergoing total thyroidectomy. Adoption of 1.1 mg/dl (12% of preoperative level) is the cutoff for determining whether to initiate prophylactic calcium replacement [7].


  Patients and methods Top


Forty patients with different thyroid diseases were candidates for total thyroidectomy in Menoufiya University Hospital and Shebin El-Kom Teaching Hospital during the period from 1 March 2011 to 1 January 2013. The patients were randomly divided into two groups: group I included 20 patients who received intraoperative intravenous 10 ml of calcium gluconate containing 500 mg of calcium injection, whereas group II included 20 patients who did not receive calcium gluconate. Serum calcium was measured preoperatively, 6 h after surgery and 5 days postoperatively. Patients with bone metastasis, patients already on calcium or vitamin D therapy and patients with bone hunger syndrome were excluded from the study. The included patients were subjected to complete history taking, laboratory and clinical examination and were prepared for elective surgery for total thyroidectomy.


  Results Top


Group I included 20 patients (five men and 15 women). The age ranged from 18 to 50 years with a mean age of 34.2 ± 9.6 years. In contrast, group II included 20 patients (three men and 17 women). The age ranged from 20 to 55 years with a mean age of 37.6 ± 9.5 years. There was no statistically significant difference between both groups with respect to age and sex (P > 0.05) [Table 1].
Table 1: Age and sex distribution of the studied groups

Click here to view


The main presenting complaint was a neck swelling-12 patients in group I and 14 patients in group II; the second complaint was toxic symptoms - seven patients in group I and five patients in group II and one patient presented with pressure symptoms in group I and one patient in group II [Table 2].
Table 2: Comparison between clinical pictures of the studied groups

Click here to view


In group I, postoperative hypocalcaemia did not occur in 12 patients (60%), one patient (5%) had severe hypocalcaemia and seven patients (35%) had mild hypocalcaemia.

However, in group II, seven patients (35%) had no hypocalcaemia, three patients (15%) had severe hypocalcaemia and 10 patients (50%) had mild hypocalcaemia [Table 3].
Table 3: Comparison between the types of hypocalcaemia in the studied groups

Click here to view


Serum calcium levels on the first postoperative day in group I patients were significantly higher than those in group II (P < 0.05): 8.1 ± 0.3 in group I and 7.8 ± 0.4 in group II. Serum calcium levels on the fifth postoperative day in group I patients were not significantly higher than those in group II patients; this is shown in [Table 4].
Table 4: Comparison between serum calcium levels on the first and fifth postoperative days in the studied groups

Click here to view



  Discussion Top


Improvement in surgical technique had led to a relevant decrease in severe postoperative complications after thyroid surgery [8]. Selection of patients who could be safely discharged on the first postoperative day remains unclear, as no scoring method exists that permits identification of those patients who will not suffer from severe hypocalcaemia [9]. In our study, we found that the incidence of temporary hypocalcaemia was 40 and 65% in group that received and did not receive calcium gluconate, respectively. However, Pfleiderer et al. [2] found that the rate of temporary hypocalcaemia after thyroidectomy was 42.6%. De Andrade Sousa et al. [10] reported that the incidence of postoperative hypocalcaemia ranges from 1.3 to 83% and the condition may go unnoticed if not investigated carefully because it is often asymptomatic. Sanabria et al. [11] found that the rate of symptomatic postoperative hypocalcaemia ranges from 5 to 50%. In addition, Baldassarre et al. [12] reported that hypocalcaemia incidence rates range widely; studies report that anywhere from 0.3 to 66.2% of patients develop hypocalcaemia after thyroid surgery.

In this study, hypocalcaemia occurred from the immediate postoperative period up to 3 days after surgery, which is in agreement with the study by Pisaniello et al. [13] who reported that hypocalcaemia can occur from 2 to 5 days after surgery. Chindavijak [14] reported that the symptom of hypocalcaemia may not occur 24 h postoperatively and may be delayed to several days. Wu et al. [15] reported that no patients developed hypocalcaemia after the third postoperative day. The critical period for serum calcium monitoring was 24-72 h after surgery.

In the present study, the incidence of severe symptomatic hypocalcaemia was lower in the group that received intraoperative calcium than the other group, which is in agreement with the study by Urno et al. [3] who reported that symptoms of hypocalcaemia, numbness and tetany were significantly lower in patients receiving calcium gluconate injection.

The calcium levels on the first postoperative day were significantly high in the group that received intraoperative calcium, which is in agreement with the study by Urno et al. [3] who reported the same result.


  Conclusion Top


The prophylactic intravenous injection of calcium gluconate during total thyroidectomy is effective in minimizing risk for postoperative symptomatic hypocalcaemia.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
CP Lombardi, M Raffaelli, P Princi, et al. Parathyroid hormone levels 4 hours after surgery do not accurately predict post-thyroidectomy hypocalcaemia. Am J Surg 2006; 140 :1016-1025.  Back to cited text no. 1
    
2.
AG, Ahmad N, Draper MR, Vrotsou K, Smith WK. The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies. Ann R Coll Surg Engl 2009; 91 :140-146.  Back to cited text no. 2
    
3.
Urno, Miyauchu A, Shimizu K. A prophylactic infusion of calcium solution reduces the risk of symptomatic hypocalcaemia in patients after total thyroidectomy in world. World J Surg 2006; 30 :304-308.  Back to cited text no. 3
    
4.
GH, V Stafyla, C Bramis, et al. Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy. World J Surg 2005; 29 :1539-1543.  Back to cited text no. 4
    
5.
Payne, MP Hier, M Tamilia, et al. Same-day discharge after total thyroidectomy: the value of 6-hour serum parathyroid hormone and calcium levels. Head Neck 2005; 21 :1-7.  Back to cited text no. 5
    
6.
Shoback. Hypoparathyroidism. N Engl J Med 2008; 359:391-403.  Back to cited text no. 6
    
7.
P, E Grosso, B Gibelli, MA Massaro, C Arrigoni, N Tradat.. Identification of patients at high risk for hypocalcaemia after total thyroidectomy. Acta Otorhinolaryngol Ital 2010; 31 :144-148.  Back to cited text no. 7
    
8.
C, Strunski V. Parathyroid risk in total thyroidectomy for bilateral, benign, multinodular goitre: report of 351 surgical cases. J Laryngol Otol 2007; 121 :237-241.  Back to cited text no. 8
    
9.
A, Bongarzoni G, Dragani G, Serafini f, et al. Should female patients undergoing parathyroid-sparing total thyroidectomy receive routine prophylaxis for transient hypocalcaemia? Am J Surg 2004; 70 :533-536.  Back to cited text no. 9
    
10.
A de Andrade Sousa, JMP Salles, JMA Soares, et al. Course of ionized calcium after thyroidectomy. World J Surg 2010; 34 :987-992.  Back to cited text no. 10
    
11.
A Sanabria, LC Dominguez, V Vega, C Osorio, D Duarte. Routine postoperative administration of vitamin D and calcium after total thyroidectomy: a meta-analysis. Int J Surg 2011; 9 :46-51.  Back to cited text no. 11
    
12.
Baldassarre RL, Chang DC, Brumund KT, Bouvet M. Predictors of hypocalcaemia after thyroidectomy: results from the nationwide inpatient sample. ISRN Surg 2012; 2012:838614.  Back to cited text no. 12
    
13.
Pisaniello D, Parmeggiani D, Piatto A, Avenia N, d′Ajello M, Monacelli M, et al. Which therapy to prevent post-thyroidectomy hypocalcaemia? G Chir 2005; 26 :357-361.  Back to cited text no. 13
    
14.
S Chindavijak. Prediction of hypocalcaemia in postoperative total thyroidectomy using single measurement of intra-operative parathyroid hormone level. J Med Assoc Thai 2007; 90 :1167-1171.  Back to cited text no. 14
    
15.
Wu SD, Gao L. Is routine calcium supplementation necessary in patients undergoing total thyroidectomy plus neck dissection? Surg Today 2011; 4 :183-188.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


This article has been cited by
1 Meta-analysis of routine calcium/vitamin D3 supplementation versus serum calcium level-based strategy to prevent postoperative hypocalcaemia after thyroidectomy
A. Sanabria,A. Rojas,J. Arevalo
British Journal of Surgery. 2019;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
Acknowledgements
References
Article Tables

 Article Access Statistics
    Viewed1190    
    Printed11    
    Emailed0    
    PDF Downloaded1179    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]