Inpatient and Outpatient Specialty Care Clinical Pathway for 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
  • Current Ca Treatment
  • Recent Ca level (within 3 months)
  • Notifies outpatient Endocrinologist of planned procedure
  • Consider placing 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
  • 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
  • Followed by
  • 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
  • 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
  • Goal: Start within 4 hours of surgery
  • Asymptomatic patients - start at lower end of suggested dose ranges
  • Symptomatic Patient
  • Consider
  • 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
   
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.