Inpatient and Outpatient Specialty Care Clinical Pathway for
Calcium Management in Children Undergoing Total Thyroidectomy

  • Preoperative Care
    • Optimize vitamin D status
    • Normalize thyroid hormone levels
    • Notify lab to anticipate need for ioPTH levels
  • Intraoperative Care
  • Place blood drawing IV
  • Obtain baseline laboratory studies with induction
    • Calcium, phosphorus, magnesium
    • Intraoperative Sampling Times of PTH (ioPTH) Assay
      • 20 minutes after induction
      • After thyroid is removed
      • After the central neck dissection
        (if indicated/performed)
      • At time of closure
  • Postoperative Treatment
    • Begin timely calcium/calcitriol supplementation based on ioPTH levels
  • Postoperative Monitoring
Postoperative Treatment Recommendation for Calcium/Calcitriol Based on ioPTH Levels and Risk of Hypocalcemia
Aim to Start within 6 hours of Surgery
ioPTH Level Treatment Escalation
High Risk
< 10 pg/mL
  • Calcium and Calcitriol Treatment
  • Give
  • Followed by
  • Asymptomatic patients – start at lower end of suggested dose ranges
  • Titration
    • Titrate the calcium and/or calcitriol if there is no improvement in calcium level
  • Contact Endocrine
  • Consider
Intermediate Risk
10-20 pg/mL
  • Calcium Treatment
  • Give
  • Asymptomatic patients – start at lower end of suggested dose ranges
  • Titration
    • Titrate the calcium and/or calcitriol if there is no improvement in calcium level
  • Contact Endocrine for:
    • Low calcium < 8.5 mg/dL
    • or
    • Elevated phosphorus > 5.5 mg/dL
Low Risk
> 20 pg/mL
  • Calcium Treatment
  • If normal calcium and phosphorus, calcium treatment not needed
  • Contact Endocrine for:
    • Low calcium < 8.5 mg/dL
    • or
    • Elevated phosphorus > 5.5 mg/dL
  • Consider:
    • Starting PO calcium carbonate
  • Medications: Calcium, Calcitriol, Thyroid Hormone Therapy
  • Laboratory Studies: Calcium, Phosphorous, PTH
  • Appointments: Surgery, ENT, Thyroid Center
Posted: March 2019
Authors: Lord, K. MD; Bauer, A. MD; Vajravelu, M. MD; Kivel, C. CRNP; Hoffman, J. MBA; Giordano, T. DNP;
Samuels, S. MD; Smith, T. CRNP; Drill, A. CRNP; Dezzi, M. CRNP; Kroeplin, G. CRNP; Durkin, M., RN; Lippold, C. RN