22q11.2 Hypocalcemia Screening/Treatment Clinical Pathway — Inpatient and Outpatient Specialty Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Related Pathways

Thyroidectomy Calcium Management, Inpatient and Outpatient Specialty Care

Peri-operative Management of Hypocalcemia in Children with 22q11.2 Deletion/Duplication

Pre-Operative Care

Scheduled Elective Procedures

Anesthesia APP Provider Reviews:
Endocrine Calcium Emergency Letter in EPIC
- Review need for stress dose calcium given evening prior to procedure
Current Ca Treatment
Recent Ca level (within 3 months)
Notifies outpatient Endocrinologist of planned procedure
Place blood drawing IV for repeating post-op Ca levels
Endocrine
Orders Ca, albumin if no results within 3 months
Documents peri-operative recommendations in EPIC

Pre-Procedural Endocrine and Genetics Evaluations/
- Scheduling with Endocrine, Urgent appointments,
- Patients without known history of hypocalcemia

Inpatient Procedures

FLOC Reviews:
- Endocrine Calcium Emergency Letter in EPIC
- Review need for stress dose calcium given evening prior to procedure
Current Ca Treatment
Recent Ca level (within 3 months)
Orders Ca, albumin if no results within 3 months
Consults Endocrine

Postoperative Hypocalcemia Treatment & Monitoring Recommendations
Symptoms of Hypocalcemia
	Monitoring	Treatment for Ca < 8.5 mg/dL	Escalation
High Risk Patient Factors History of hypocalcemia with procedures/illness, or baseline requirement for calcium and/or calcitriol supplementation Procedure Factors Longer/more invasive procedures Delayed transition to PO/usual enteral intake	All patients Post-op Ca within 1-4 hours post procedure if procedure lasts ≥ 2 hours Inpatient Continue Ca monitoring every 4-6 hours Discontinue if 2 Ca ≥ 8.5 mg/dL more than 8 hours apart Outpatient Review patient’s post-discharge Ca monitoring plan Typically, if Ca normal, check 2-3 days post-discharge Labs ordered by primary endocrinologist	Consult Endocrine Give IV Calcitriol in the OR/Recovery rm Followed by Oral/IV Calcitriol and Oral Calcium as soon as able to tolerate PO Goal: Start within 4 hours of surgery Asymptomatic patients Start at lower end of suggested dose ranges Titration Titrate the calcium and/or calcitriol with support of Endocrine consult if there is no improvement in Ca level	Symptomatic Patient Consider Oral/IV Calcitriol IV Calcium Transfer to ICU
Intermediate Risk Patient Factors History of mild hypocalcemia with procedures/illness Procedure Factors Longer/more invasive procedures Delayed transition to PO/usual enteral intake	All patients No routine post-procedure Ca monitoring. Obtain post-procedure Ca if patient is not back to baseline (sedated, not taking PO well) within 4 hours Inpatient Continue Ca monitoring every 4-6 hours Discontinue if 2 Ca ≥ 8.5 mg/dL more than 8 hours apart Outpatient Review patient’s post-discharge Ca monitoring plan Typically check Ca 2-3 days post-discharge Labs ordered by primary endocrinologist	Consult Endocrine Give Oral/IV Calcitriol and Oral Calcium Goal: Start within 4 hours of surgery Asymptomatic patients - start at lower end of suggested dose ranges	Symptomatic Patient Consider Oral/IV Calcitriol IV Calcium Transfer to ICU If asymptomatic: Consider increasing enteral calcium carbonate and/or enteral calcitriol
Low Risk Patient Factors No known history of hypocalcemia Procedure Factors Short procedure with quick post-procedure transition to home feeding regimen	No routine post-op Ca monitoring required Review symptoms of hypocalcemia with family prior to discharge

Discharge Recommendations

Posted: May 2021
Authors: E. Mancilla, MD; L. Katz, MD; V. Bamba, MD; M. Vajravelu, MD; A. Weintraub, MD; D. McDonald-McGinn, MS, CGC; T. Dea, CRNP; J. Zook, PharmD; T. Crowley.

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Inpatient and Outpatient Specialty Care Clinical Pathway for Peri-operative Management of Hypocalcemia in Children with 22q11.2 Deletion/Duplication

Evidence