Tetany following thyroidectomy - Forum

[Marcel]

39 year old female undergoes near total thyroidectomy for a "huge" mutinodular goitre. The surgeon says he left behind sufficient lobe on right side and a none (?) on the left side. the pt has an uneventful recovery until 3 days PO when she develops pain all over body, tingling and carpopedal syndromes. S calcium which was 9mg% preop is 5mg%. She is treated with IV calcium at high dose. 20 ml 10% Ca salt IV 8 hourly. The pt is still having pain and tingling all over the body. What is the standard treatment in this problem. What is the prognosis.

[Lady Surgeon]

I think that patients with permanent hypoparathyroidism usually have a rapid drop in their calcium immediately post-op, not three days later. So maybe your patient will have some recovery of her parathyroid function over the next 3 months. In the meantime continue supplementing her calcium with iv calcium as you are doing. I would go ahead and start her on 2 grams of oral calcium daily now. Also, be sure her magnesium is okay; it will probably be low also. Supplementing the magnesium will help raise the calcium-- I forget the mechanism. If the hypocalcemia is permanent she will need to be on vitamin D (Rocaltrol), and calcium for the rest of her life. Dosage range for Rocaltrol is 0.25 micrograms to 2 micrograms daily. She will need to be hospitalized until the calcium is stabilized on oral medications only. If you get her calcium level up her symptoms will resolve.

[Dottore]

First: The surgeon must be sure that he identified and took care about the parathyroid glands (there are some surgeons who think it's not necessary, I don't think so).

Second: wait for patohologyst's report (it's very helpful to know what happened with the glands).

With all that information plus the clinical evolution, you can clarify if you are dealing with a transient or permanent hypoparathyroidism. The first one almost always recovers (When the impaired irrigation to the glands improves), this take some weeks (months) and the treatment is suplementary doses of vitamin D , calcium (IV--->oral) and a lot of patience.For the second one there is no solution and will need treatment lifelong, but sometime improves in relation with doses and tolerance to hypocalcemic simptoms. In both take care with the kidneys (nephrocalcinosis).

[surgery]

It can be difficult to preserve the parathyroids when operating on huge goiters. My guess is that the patient will prove to be permanently hypoparathyroid although there is a chance that this is temporary and will recover. In addition to giving the patient IV calcium, I would start the patient on oral calcium carbonate 5 gms daily and 1,25 dihydroxycalciferol (Rocaltrol) 1 microgram daily. Make sure the the patient is not also hypomagnesemic. If necessary give IV Mg. Eventually you will be able to wean the patient off IV Ca and maintain on oral calcium and Rocaltrol.