Benefits Resulting from 1-and 6-Hour Parathyroid Hormone and Calcium Levels After Thyroidectomy

OBJECTIVE: Previous studies have established the efficacy of post-thyroidectomy hypocalcemia monitoring using parathyroid hormone (PTH) and corrected calcium levels at 1 and 6 hours. The goal of this study was to measure the impact of managing patients based on the above findings with respect to: duration of hospital stays, rates of transient hypocalcemia, number of blood tests, cost savings, and discharge from the hospital as early as 8 hours post-thyroidectomy without compromising safety. STUDY DESIGN AND SETTING: This is a prospective study involving 95 total thyroidectomy patients using historical data as controls. The previous protocol was modified in that all blood tests ceased for patients meeting the 6-hour critical level of PTH ≥ 28 ng/L and simultaneous corrected calcium ≥ 2.14 mmol/L (8.56 mg/dL). Furthermore, patients with 1-hour PTH levels ≤ 8 ng/L were prophylactically treated with calcium and vitamin D supplementation. RESULTS: This study demonstrates lower rates of transient hypocalcemia from 28% to 9% (OR = 4.13, P = 0.016), a 10-hour reduction in mean hospital stay, and fewer blood tests (23 vs 15) for patients undergoing total thyroidectomy since the implementation of the new protocol. Furthermore, the experimental protocol resulted in an average cost savings of $766 per patient. CONCLUSIONS: The new algorithm resulting from PTH and corrected calcium monitoring at 1 and 6 hours post-thyroidectomy has led to significant cost savings for our institution. It has also translated into greater patient satisfaction as a result of fewer blood tests, a lower incidence of transient hypocalcemia, and significantly shorter hospital stays.

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Safety, Efficacy, and Cost Savings of Single Parathyroid Hormone Measurement for Risk Stratification after Total Thyroidectomy

The American Surgeon ◽

10.1177/000313481307900816 ◽

2013 ◽

Vol 79 (8) ◽

pp. 768-774 ◽

Cited By ~ 10

Author(s):

Meghan McCullough ◽

Collin Weber ◽

Chris Leong ◽

Jyotirmay Sharma

Keyword(s):

Parathyroid Hormone ◽

Risk Stratification ◽

Total Thyroidectomy ◽

Calcium Supplementation ◽

Cost Savings ◽

Day Surgery ◽

Laboratory Cost ◽

Number Of Patients ◽

Same Day Discharge ◽

Hospital Stays

The management of hypocalcemia (HC) after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of parathyroid hormone (PTH) level after TTx may allow for prediction of postoperative HC and lead to shorter hospital stays. A prospective database was queried between January 2010 and June 2012 with 95 patients who had undergone TTx identified. Patient demographics; preoperative diagnosis; laboratory values and cost; complications; intravenous calcium supplementation; and length of stay (LOS) were analyzed. A PTH-based algorithm was retrospectively applied and theoretical cost savings were analyzed in terms of laboratory cost, LOS, and total cost. Ninety-five patients underwent TTx: 37 patients (38.9%) had cancer, whereas 27 (28.4%) had Graves’ disease and the remaining 31 (32.6%) had a benign multinodular goiter. Postoperative PTH was recorded in 72 patients (74.4%); 46 (63.8%) had PTH greater than 10 pg/mL and 26 (36.9%) had PTH less than 10 pg/mL. Transient HC occurred in 10 patients (38.4%) with PTH less than 10 pg/mL (relative risk, 17.69; P = 0.0001). Patients with PTH less than 10 pg/mL incurred a 14.9 per cent higher hospital cost compared with those with PTH greater than 10 pg/mL. With retrospective implementation of the algorithm, there is a potential 46.4 per cent cost savings for the PTH less than 10 pg/mL group, 67.3 per cent savings for the PTH greater than 10 pg/mL group, and 46.7 per cent savings when taken altogether. Algorithmic risk stratification based on postoperative PTH less than 10 pg/mL serves as both a sensitive (100%) and specific (76.7%) predictor of postoperative HC. Such risk stratification may allow for same-day discharge in a number of patients, and even in patients requiring an overnight stay, result in cost savings as a result of a reduction in laboratory expenditures.

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Next-day Parathyroid Hormone as a Predictor of Post-thyroidectomy Hypocalcemia

World Journal of Endocrine Surgery ◽

10.5005/jp-journals-10002-1192 ◽

2016 ◽

Vol 8 (3) ◽

pp. 203-207 ◽

Cited By ~ 1

Author(s):

MJ Paul ◽

Thomas V Paul ◽

Deepak T Abraham ◽

Anish Cherian

Keyword(s):

Parathyroid Hormone ◽

Total Thyroidectomy ◽

Predictive Value ◽

Calcium Supplementation ◽

Early Discharge ◽

Tertiary Hospital ◽

Vitamin D Supplementation ◽

Postoperative Hypocalcemia ◽

Parathyroid Dysfunction ◽

Pth Level

ABSTRACT Aims Total thyroidectomy is significantly complicated by parathyroid dysfunction and hypocalcemia. These aspects impact the decision regarding the timing of discharge and quantum of calcium supplementation required. Therefore, we aimed at evaluating the accuracy of next-day parathyroid hormone (PTH) level as a predictor of post-thyroidectomy hypocalcemia. Secondly, we aimed at establishing our institution's postoperative PTH level, which can accurately predict the development of post-thyroidectomy hypocalcemia to help us ensure the safe and early discharge of patients. Materials and methods A prospective observational study of 50 continuous patients undergoing thyroidectomy was conducted at a tertiary hospital in South India. Postoperative blood samples were collected for estimation of PTH, calcium, albumin, and phosphorous. The data were collated and results analyzed using Stata I/C 10.1. Results A total of 30% (15/50) of the patients had postoperative hypocalcemia (serum calcium <8 mg/dL). Postoperative PTH was low (<8 pg/mL) in 40% (20/50) of patients. There was a significant association between PTH < 8 pg/mL and the presence of postoperative hypocalcemia (p = 0.029). The area under the receiver operating characteristic (ROC) curve was 0.7, and a next-day PTH of <6 pg/mL showed the highest sensitivity and specificity (83 and 60% respectively) for the development of postoperative hypocalcemia, with a positive predictive value (PPV) and negative predictive value (NPV) of 83 and 60 respectively. Conclusion The PTH assessment performed the day after surgery is an acceptable test to predict post-thyroidectomy hypocalcemia; PTH <6 pg/mL can be used as our institution's cutoff value. Department protocols for calcium and vitamin D supplementation following total thyroidectomy may be formulated based on the appropriately timed local postoperative PTH value to assist safe and early discharge of patients. Clinical significance Discharge protocols for patients undergoing thyroidectomy may be formulated based on the postoperative PTH values, thus enabling safe and early discharge of patients. How to cite this article Cherian AJ, Ramakant P, Paul TV, Abraham DT, Paul MJ. Next-day Parathyroid Hormone as a Predictor of Post-thyroidectomy Hypocalcemia. World J Endoc Surg 2016;8(3):203-207.

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Management of Completion and Total Thyroidectomy Patients Based on 1-Hour Postoperative Parathyroid Hormone

The American Surgeon ◽

10.1177/000313481608201004 ◽

2016 ◽

Vol 82 (10) ◽

pp. 881-884

Author(s):

Joshua Park ◽

Ethan Frank ◽

Alfred Simental ◽

Sara Yang ◽

Christopher Vuong ◽

...

Keyword(s):

Vitamin D ◽

Parathyroid Hormone ◽

Total Thyroidectomy ◽

Early Discharge ◽

Vitamin D Supplementation ◽

Initial Management ◽

Management Protocol ◽

Symptomatic Hypocalcemia ◽

Risk Patients ◽

One Year

After thyroid surgery, protocols based on postoperative parathyroid hormone (PTH) levels may prevent symptoms of hypocalcemia, while avoiding unnecessary prophylactic calcium and/or vitamin D supplementation. We examined the value of an initial management protocol based solely on a single PTH level measured one hour after completion or total thyroidectomy to prevent symptomatic hypocalcemia by conducting a retrospective review of 697 consecutive patients treated from July 2003 to April 2015. The proportion of patients who developed symptomatic hypocalcemia was similar between those treated before (n = 155) and after (n = 542) implementation of this 1-hour PTH protocol (16.8% vs 15.9%; P = 0.786). Those in the 1-hour PTH groups had lower overnight observation rates (97.4% vs 53.7%; P < 0.001) and length of stay (1.98 ± 2.61 vs 0.89 ± 1.87 days; P < 0.001), and required less calcium (3.9% vs 0.8%; P = 0.015) and vitamin D (2.6% vs 0%; P = 0.002) supplementation one year after surgery. Less than 1 per cent of patients discharged on the day of surgery in accordance with the 1-hour PTH guidelines returned to the emergency room for symptomatic hypocalcemia; none experienced significant morbidity. This protocol facilitates early discharge of low-risk patients and results in a similar or improved postoperative course compared with traditional overnight observation.

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Parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302012000300003 ◽

2012 ◽

Vol 56 (3) ◽

pp. 168-172 ◽

Cited By ~ 18

Author(s):

Felipe Augusto Brasileiro Vanderlei ◽

Jose Gilberto Henriques Vieira ◽

Flavio Carneiro Hojaij ◽

Onivaldo Cervantes ◽

Ilda Sizue Kunii ◽

...

Keyword(s):

Vitamin D ◽

Parathyroid Hormone ◽

Total Thyroidectomy ◽

Serum Calcium ◽

Vitamin D Supplementation ◽

Cutoff Value ◽

Increased Risk ◽

Symptomatic Hypocalcemia ◽

Early Predictor ◽

Selection Of

OBJECTIVE: The purpose of this study was to evaluate if the measurement of peri-operative parathyroid hormone (PTH) is able to identify patients with increased risk of developing symptoms of hypocalcemia. SUBJECTS AND METHODS: Forty patients who underwent total thyroidectomy were studied prospectively. Ionized serum calcium and PTH were measured after induction of anesthesia, one hour (PTH1) and one day after surgery (PTH24). Patients were evaluated for symptoms of hypocalcemia and treated with calcium and vitamin D supplementation as necessary. RESULTS: Symptomatic hypocalcemia developed in 16 patients. Symptomatic patients had significant lower PTH1 and greater drops in PTH levels. The selection of 12.1 ng/L as PTH1 level cutoff level divided patients with and without symptoms with 93.7% sensitivity and 91.6% specificity. The selection of 73.5% as the cutoff value for PTH decrease resulted in 91.6% sensitivity and 87.5% specificity. CONCLUSION: PTH1 levels and the drop in PTH levels are reliable predictors of developing symptomatic hypocalcemia after total thyroidectomy.

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The Value of Postoperative Parathyroid Hormone Levels in Predicting the Need for Long-Term Vitamin D Supplementation after Total Thyroidectomy

Annals of Surgical Oncology ◽

10.1245/s10434-010-1377-5 ◽

2010 ◽

Vol 18 (3) ◽

pp. 777-781 ◽

Cited By ~ 18

Author(s):

Tracy S. Wang ◽

Ashley K. Cayo ◽

Stuart D. Wilson ◽

Tina W. F. Yen

Keyword(s):

Vitamin D ◽

Parathyroid Hormone ◽

Total Thyroidectomy ◽

Vitamin D Supplementation ◽

Hormone Levels

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The impact of age and oral calcium and vitamin D supplements on postoperative hypocalcemia after total thyroidectomy. A prospective study

BMC Surgery ◽

10.1186/1471-2482-13-s2-s11 ◽

2013 ◽

Vol 13 (Suppl 2) ◽

pp. S11 ◽

Cited By ~ 11

Author(s):

Salvatore Tolone ◽

Ruggiero Roberto ◽

Gianmattia del Genio ◽

Luigi Brusciano ◽

Domenico Parmeggiani ◽

...

Keyword(s):

Vitamin D ◽

Prospective Study ◽

Total Thyroidectomy ◽

Postoperative Hypocalcemia ◽

Oral Calcium ◽

Vitamin D Supplements ◽

A Prospective Study ◽

The Impact

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Detrimental Impact of Interferon-Based Regimens for Chronic Hepatitis C on Vitamin D/Parathyroid Hormone Homeostasis

The Open Rheumatology Journal ◽

10.2174/1874312901812010279 ◽

2018 ◽

Vol 12 (1) ◽

pp. 279-288 ◽

Cited By ~ 1

Author(s):

Livia Salmi ◽

Matteo Nazzareno Barbaglia ◽

Carlo Smirne ◽

Sara Bianco ◽

Giulia Guaschino ◽

...

Keyword(s):

Vitamin D ◽

Chronic Hepatitis ◽

Parathyroid Hormone ◽

Hepatitis C ◽

Chronic Hepatitis C ◽

Sustained Viral Response ◽

Vitamin D Supplementation ◽

The Other ◽

Ifn Treatment ◽

The Impact

Background: Both the anti-infective and anti-inflammatory properties of vitamin D, an essential hormone of calcium homeostasis, have ample support in the literature. The high rates of vitamin D deficiency among patients with chronic hepatitis C are also well known. That supplementation with vitamin D may boost sustained viral response rates in vitamin D deficient, hepatitis C virus (HCV) infected patients undergoing Interferon-alpha (IFN) treatment, on the other hand, is controversial. Surprisingly, studies considering in this latter setting what are the effects of IFN treatment (with or without vitamin D supplementation) on the other major regulator of mineral metabolism, i.e. the Parathyroid hormone (PTH), are lacking. Aim: Evaluate the impact of interferon-based treatment against HCV (±cholecalciferol supplementation) on vitamin D and PTH homeostasis. Methods: A series of 40 consecutive patients received pegylated IFN plus ribavirin to treat chronic hepatitis C. At the discretion of their physician, some of them (N. = 27) received vitamin D supplementation while others did not (N. = 13). All had measured plasma 25-hydroxycholecalciferol and PTH concentrations at baseline, at completion of the 4th (TW4) and 12th treatment week (TW12) and at 24 weeks after the end of therapy (SVR24). Results: Plasma PTH concentration increased significantly from baseline during treatment, raising to 44.8 [30.7-57.2] pg/mL at TW4 (p=0.01), 47.0 [37.1-63.2] pg/mL at TW12 (p=0.006) to return to baseline levels in the follow-up (34.5 [27.6-43.0]; p=0.16). The proportion of patients who satisfied criteria for hyperparathyroidism was higher at TW12 (N=10, 25%) than at TW4 (N=6, 15%). There was no statistical correlation between vitamin D and PTH blood levels (ρ=-0.07; p=0.65). Conclusion: An increase in plasma PTH occurs systematically during IFN treatment of HCV patients and cannot be prevented by vitamin D supplementation.

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141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

British Journal of Surgery ◽

10.1093/bjs/znab259.1070 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

A Nathan ◽

N Hanna ◽

A Rashid ◽

S Patel ◽

Y Phuah ◽

...

Keyword(s):

Radical Prostatectomy ◽

Cost Savings ◽

Clinical Indication ◽

Validation Dataset ◽

Complication Rates ◽

Robot Assisted ◽

Blood Tests ◽

Significant Difference ◽

New Guidelines ◽

The Impact

Abstract Objectives Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT. Method The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients. Results Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p < 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient. Conclusions Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

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A Written Guideline Implementation Can Lead to Reductions in Laboratory Testing in an Intensive Care Unit

Anaesthesia and Intensive Care ◽

10.1177/0310057x9702500106 ◽

1997 ◽

Vol 25 (1) ◽

pp. 33-37 ◽

Cited By ~ 7

Author(s):

S. M. Mehari ◽

J. H. Havill ◽

C. Montgomery

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Laboratory Testing ◽

Cost Savings ◽

Blood Gases ◽

Arterial Blood Gases ◽

Blood Tests ◽

Arterial Blood ◽

The Impact

The impact of developing guidelines for laboratory testing in an Intensive Care Unit (ICU) was examined. Targeted blood tests were recorded on fifty cardiac surgery and fifty general intensive care patients retrospectively. Following the introduction of guidelines, the study was repeated with prospective data collection. Comparison of the samples before and after the intervention showed a 25.9% reduction in all blood tests and a 17.1% reduction in arterial blood gases in the post cardiac surgery group. In general ICU patients, the drop in all tests was 16.6% and in arterial blood gases 21.9%. The cost savings from the cardiac surgery sample was N.Z.$3,637 and general ICU N.Z.$3,166, giving a sum total of N.Z.$6,803 in 100 patients. The potential cost savings for the annual admissions of 1,200 patients is N.Z.$81,636. This study shows that written guidelines can bring about major cost reduction in the short-term.

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