Postoperative Management

A successful parathyroidectomy results in normalization of the calcium level. This level usually reaches its nadir 36 to 48 hours after the operation. Postoperative hypocalcemia is common in patients with severe skeletal calcium depletion, commonly referred to as "bone hunger." This can be predicted preoperatively as such patients have an elevated preoperative alkaline phosphatase level with otherwise normal liver function tests. Clinical manifestations of hypercalcemia are perioral numbness, tingling of the fingers, muscle cramps, anxiety, trembling of the masseter muscle, contraction with facial nerve stimulation anterior to the ear (Chvostek's sign), carpopedal spasm (Trousseau's sign), convulsions, and opistho-tonus. If mild symptoms appear, calcium supplementation should be given orally with calcium carbonate (500 to 1,000 mg three times daily). If symptoms are moderate, the calcium dose can be increased, and calcitriol (0.25 to 1.0 mg orally twice daily 1,25-dihydroxyvitamin D [Rocaltrol]) is additionally provided. The vitamin D facilitates gastrointestinal calcium absorption and calcium mobilization from the skeleton.

If symptoms are severe, one ampule of 10% calcium gluconate (90 mg elemental calcium) dissolved in 100 cc of normal saline should be administered intravenously over 15 minutes, followed by a constant infusion of calcium (10 ampules in 10% calcium gluconate in 1,000 cc of normal saline) at 20 to 100 cc/hour, if needed. It is essential to avoid extravasation of intravenous calcium because skin necrosis may result. Hyperventilation and vomiting should be addressed because alkalosis aggravates symptoms. Serum calcium and magnesium levels should be checked if symptoms occur. Hypomagnesemia can cause symptoms similar to hypocalcemia. Patients should be educated about the warning signs and instructions given for appropriate action, if necessary. For limited, focused, unilateral operations, same-day discharge has been recommended, whereas 23- or 24-hour observation remains the standard for bilateral explorations. The latter is mainly recommended because, rarely, a bleeding complication may result in respiratory distress, warranting immediate evacuation.

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