Hypoglycemiain diabeticpatientswithPTDoverleftlegformorethanayear.ppt

Hypoglycemia in diabetic patients with PTD over left leg for more than year

1. Dr Guy ANDRY, M. MOREAU, I.EL MOUSSAOUI,
E. WILLEMSE, M. QUIRINY, A. DIGONNET
Université Libre de Bruxelles, Brussels

2. Despite all the methods to evaluate and to
predict postoperative hypocalcemia, no
consensus existson the roleof routine calcium
and/or Vit. D followingthyroidsurgery
MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA

3. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Hypocalcemia isthe mostfrequentcomplication
aftertotal thyroidectomy
Transient: 9 to 50 %
Permanent: 0.5 to 13% (→ 33 %)

4. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Patients and methods
Patients wereprospectivelyregisteredfromJanuary2006 till
December2009.
Calcemia(phosphoremia) preand postop
Pth levels
Afterthe first bloodsample(2 to 3 hourspostop.):
calcium gluconate 2 g/l of perfusion if calcemia≤ 8.2 mg/dl
Symptomsand signsof hypocalcemiaregistered

5. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Patients and methods
Frompostopday1 to day2 (discharged): pth, calcemia,
phosphoremia
Treatmentfor Ca < 8.0 mg/dl for 8.0 < Ca < 8.3 mg/dl
-1 g calcium carbonate TID -1g calcium BID
-Alfacalcidiol1 mcg/day -Alfacalcidiol1 mcg/day0.5 mcg/day
Day 6 to 10 (outpatientclinic): pth, calcemia, phosphoremiaand
OH-vitD, TSH; T4L, …

6. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Materials& methods
Pthleveland calcemia: between5th and 10th daypostop,
after1 month, 3 months, 6 to 9 months, 1 year; 1/yr
thereafterif prolongedhypocalcemia

7. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results(1)
(near) total thyroïdectomy(or totalisation): 537 pts from
Jan 2006 till Dec2009 (421:W; 116:M)
Meanage: 51 yrs(12-82)
Selectiveneck dissection (mainlycentral compartment: 63
pts)
Cancer: 81 pts (72 PTC, 5 MTC, 4 follicular)
Multinodulargoiter: 415 (50 withthroiditis)
Basedow : 29
12 pts (benighadenomas, follicularnodule, …)

8. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results(2)
43.4% (n=233) developpeda transienthypocalcema
3.91% (n=21) developpeda 1 yearhypocalcemia
3.17% (n=17) prolongedhypocalcemia
4 PTS hada PTH normal level15, 23, 32, 39 pg/ml
but maintainedcalcemicsupplementsto avoid
symptoms

9. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results(4)
PTS characteristicsfor prolongedhypocalcemia
No (n=520)Yes(n=17) Pvalue
Malignant 14.6% 43.8%
ParathyroidI&P*
1.2
3
4
1.9%
6.5%
91.6%
11.8%
17.6%
70.6%
Lymphnode
dissection
11.2% 29.4%
Weightof specimen 47.5 (SD 
49.5)
55.4 (SD 55.1)0.51
Hospstay(d) 4.08 (SD 
0.79)
4.2 (SD 0.84) 0.79
* Identified and Preserved
0.001
0.022
0.004

10. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results(6)
Sensibility, specificity, ODDS ratio of hypocalcemiahypoPTHto predict
«definitive» hypocalcemia
Ca: calcemia; PTH: levelof «intact» on ice; 4 hrs: 4 hourspostop; J1 to x: J postop1 to x
SensitivitySpecificityODD1
ratio
Pvalue
Ca 4 hrs< 8 mg/dl
Ca J1 < 8 mg/dl
Ca J5-20 < 8 mg/dl
Ca J30 < 8 mg/dl
17.65%
70.60%
92.30%
31.30%
90.3%
64.7%
94.3%
98.3%
2
4.4
196.1
25.6
0.28
0.0029
< 0.0001
<0.0001
PTH 4 hrs< 15 pg/ml
PTH J1 < 15 pg/ml
PTH J5-20 < 15 pg/ml
PTH J30 < 15 pg/ml
100%
100%
90%
63.6%
62.4%
56.4%
68.5%
92.2%
∞
∞
19.6
20.7
<.0001
<.0001
<.0001
<.0001

11. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Discussion (1)
HypocalcemiapostopJ5-20: < 8 mg/dl (sens: 92.3%;
specif: 94.3%)
Hypo PTH levelpostop< 15 pg/ml
are predictiveof definitivehypocalcemia
ROC curvewasconstructedPTH early< 9 pg/ml ispredictive
of definitivehypocalcemia:
100% sensitivity
76% specificityODDS ratio ∞ p < 0.0001

12. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Discussion (2)
Laterecoveryof normal parathormone activity
Among21 PTS withprolongedhypocalcemia
4 showednormal calcemiaand PTH levelsafter4, 5, 6 and
7 yrs(4 parathyroidsrespectedduringthe operation;2 M,
2W; 3 MN Goiters, 1 Basedow)

13. MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Role of postoperative vitamin D and/or calcium routine
supplementation in preventing hypocalcemia after
thyroidectomy: a systematic review and meta-analysis
A. Alhefdhi et al, The Oncologist 2013;18:539-542

14. Roleof postoperativevitaminD and/or calcium routine
supplementationin preventinghypocalcemiaafterthyroidectomy:
a systematicreviewand meta-analysis(1)
Outof1180studiesonhypocalcemiapostTthyroidectomy
9studiesrespondingtothestrengthofrecommendationtaxonomy
gradingsystem(SORT)*
*EbellM.H.2004,J.Am.BoardFam.Pract.
N = 2285 PTS
Symptomatic
hypocalcemia(%)
22 PTS : vit D only
580 PTS : Ca
++
only
792 PTS : vit D + Ca
++
891 PTS : no
4.6 %
14 %
14 %
20.5 %
After A. ALHEFHI & al 2013

15. Conclusion
SystematicassaysofiPTHat4hrs
Ca
++
betweenD5-20
areagoodindicatorsofprolonged,hypoparathyroidism
hypocalcemia.
ImmediatepostopadministrationofIVCa
++
gluconate
(2g/l)followedatD
1-2bycalcidial1mgandcalcium
carbonate(1to6gtailorizedbyCa
++
levels)preventthe
stressofsymptomatichypocalcemic.
MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA