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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 184-187

Calcium and Vitamin D supplementation in the prevention of post-operative hypocalcaemia in thyroidectomy


Department of General Surgery, Government Medical College, Kozhikode, Kerala, India

Date of Submission29-Jul-2020
Date of Decision13-Aug-2020
Date of Acceptance04-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Vishnu Santhosh Menon
Karthiayini Mandiram, Post Pulasseri, Pattambi Taluk, Palakkad - 679 307, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_7_20

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  Abstract 


Introduction: The incidence of transient hypocalcaemia after thyroidectomy varies in centres. It increases morbidity and delays discharge. This randomised controlled trial aimed to ascertain the usefulness of calcium and Vitamin D supplementation for 1 week pre-operatively in the prevention of hypocalcaemia in patients undergoing total thyroidectomy (TT) for multi-nodular goitre. Methodology: Patients undergoing TT for multi-nodular goitre from January 2019 to August 2019 were included in the study. They were randomly divided into two groups by block randomisation. Group A received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mg every 6 h) 7 days before surgery and Group B did not receive supplementation. Symptoms and signs of hypocalcaemia were monitored. Calcium profile was measured pre-operatively and post-operatively at 6 h, 24 h, 72 h and 14th day. Serum calcium level ≤8.5 mg/dl was considered as hypocalcaemia. Results: 8/62 patients in Group A and 26/62 in Group B had symptoms of hypocalcaemia. 11/62 patients in Group A and 34/62 in Group B developed signs of hypocalcaemia. 15/62 patients in Group A and 36/62 in Group B had biochemical hypocalcaemia. 9/62 patients in Group A and 25/62 in Group B developed post-operative hypocalcaemia, which required post-operative oral supplementation. 3/62 patients in Group A and 16/62 in Group B needed post-operative intravenous calcium supplementation. Conclusions: It is concluded that post-operative hypocalcaemia which manifested as signs and symptoms and correlated with biochemical values was lower after receiving pre-operative oral calcium and Vitamin D3 supplement for 7 days. The need for post-operative supplementation was lower in this group.

Keywords: Calcium, post-operative hypocalcaemia, thyroidectomy, Vitamin D


How to cite this article:
Menon VS, Kumar T R, Unnikrishnan E P, Gopi E V. Calcium and Vitamin D supplementation in the prevention of post-operative hypocalcaemia in thyroidectomy. Kerala Surg J 2020;26:184-7

How to cite this URL:
Menon VS, Kumar T R, Unnikrishnan E P, Gopi E V. Calcium and Vitamin D supplementation in the prevention of post-operative hypocalcaemia in thyroidectomy. Kerala Surg J [serial online] 2020 [cited 2020 Dec 5];26:184-7. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/184/300245




  Introduction Top


Reduction in mortality and morbidity following total thyroidectomy (TT) is currently discussed. The quality of surgery is determined by the severity of post-operative hypocalcaemia, which is classified as transient lasting for up to 6 months of surgery and permanent lasting beyond 6 months.[1] Studies have noted up to 50% of transient and 5% of permanent hypocalcaemia after TT.[2],[3] Common causes of post-thyroidectomy hypoparathyroidism are inadvertent removal of parathyroids, manipulation of parathyroids and thyroid vasculature ranging from temporary vasospasm to devascularisation, haemodilution during intravenous fluid administration during surgery, increased calcium excretion in response to stress and calcitonin release during manipulation of thyroid tissue during surgery.[4] Other factors include acid-base imbalances during surgery, pre-existing hypocalcaemia, vitamin deficiency and disorders of magnesium imbalances.[5],[6] Several strategies have been adopted for conserving calcium level after thyroidectomy and to decrease symptoms of hypocalcaemia.[7] It is a routine practice to check hypocalcaemia symptoms in the post-operative period and measuring serum calcium. Educating the patients on the symptoms of hypocalcaemia before discharging from the hospital is important. If hypocalcaemia develops, the approach to treatment depends on speed of onset, biochemical severity and clinical features.[5] It is usually transient, but is of main concern as it requires either prolonged stay in the hospital or readmission.[7]

A high prevalence of Vitamin D deficiency has been demonstrated in various parts of India and is a known risk factor for post-operative hypocalcaemia after TT.[8] Moore gave oral calcium at 5 g/day for 2 weeks, with some patients developing increased lethargy and other features of hypercalcaemia.[9] Others used 3 g/day oral calcium given post-operatively and 2 g of oral calcium, respectively, pre-operatively.[10],[11] They showed that pre-operative serum calcium was the only independent parameter, which could predict 24 h post-operative hypocalcaemia. Malik et al. have also shown the benefits of pre-operative calcium and vitamin D3 supplementation.[12] However, the role of pre-operative supplementation has seldom been tested. The aim of this study was to ascertain the usefulness of pre-operative calcium and Vitamin D supplementation in the prevention of hypocalcaemia after TT.


  Methodology Top


This was an interventional randomised control study. Patients aged 18 and 60 years, who underwent TT for multi-nodular goitre from January 2019 to August 2019 at Government Medical College Hospital, Kozhikode, were included in the study. Any patient with a history of prior neck surgeries and patients who had received calcium supplementation prior to study or pre-existing hypocalcaemia were excluded. They were randomly divided into two groups of 62 each by block randomisation. Group A received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mg every 6 h) 7 days before surgery and Group B did not receive supplementation. Pre-operative assessment, anaesthetic and surgical technique for TT were used for all patients. Surgeons were blinded as to which group the patients belonged. Symptoms and signs of hypocalcaemia were monitored and calcium profile was measured pre-operatively and post-operatively at 6 h, 24 h, 72 h and 14th day. The effectiveness of the intervention was assessed by means of comparing five parameters post-operatively, serum total calcium, presence of signs and symptoms of hypocalcaemia, whether oral calcium and Vitamin D3 had to be supplemented because of the post-operative hypocalcaemia and whether intravenous calcium gluconate had to be given for hypocalcaemia. The blood tests for serum calcium and serum albumin assessment were done. Hypocalcaemia was defined as serum total calcium adjusted for serum albumin below 8.5 mg/dl. The collected data were entered and analysed using computer software, SPSS version 20.


  Results Top


The mean age of the distribution was 42.96 ± 10.63 years in Group A (intervention group) and 45.22 ± 10.46 years in Group B. In all 124/124 cases, parathyroids were identified and preserved. There was no other major complications associated with the surgery including recurrent laryngeal injury, haematoma or wound infection. 24/124 patients had vocal changes which were not associated with stridor. Seven out of this had hoarseness all of which improved in 2 weeks [Table 1].
Table 1: Clinical parameters in the two groups

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Overall, the incidence of hypocalcaemia was 41% and clinically having either symptoms or signs was 28% [Table 2] and [Table 3]. However, none developed permanent hypocalcaemia. 8/62 patients in Group A and 26/62 in Group B had symptoms of hypocalcaemia. 11/62 patients in Group A and 34/62 in Group B developed signs of hypocalcaemia.
Table 2: Symptoms of hypocalcaemia

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Table 3: Signs of hypocalcaemia

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15/62 patients in Group A and 36/62 in Group B had biochemical hypocalcaemia. 9/62 patients in Group A and 25/62 in Group B required post-operative oral supplementation, and 3/62 patients in Group A and 16/62 in Group B needed post-operative intravenous calcium supplementation. In all these instances, the P value was <0.05 [Table 4]. On statistical analysis, significance for the intervention was found only at 6 h post-operative calcium levels (P = 0.002). Even though the intervention Group A who received the intervention had a higher calcium levels than Group B also at 24 h, 72 h and 2 weeks, the significance was low i.e., P > 0.05.
Table 4: Postoperative calcium levels and need for intervention in the two groups

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  Discussion Top


Hypocalcaemia after TT is a common complication, ranging from 50% of transient and 4% permanent hypocalcaemia after thyroidectomy.[2] Baldassarre et al. reported an incidence of hypocalcaemia after thyroidectomy as 5.5%.[3] Although serum calcium assay has been used to predict hypocalcaemia after the TT, due to post-operative haemodilution, the measurement of total serum calcium may yield inaccurate results.[13],[14] Extensive research has been done on the value of the parathyroid hormone (PTH) in predicting post-thyroidectomy hypocalcaemia.[15] However, these are not very effective and easily available. Hence, there is a need for strategies to reduce or even prevent post-operative hypocalcaemia. The literature is replete with studies evaluating the effect of calcium and Vitamin D supplementation on hypocalcaemia after TT.

Docimo et al.[16] found the incidence of symptomatic hypocalcaemia as 6% and laboratory hypocalcaemia as 10%. No permanent hypocalcaemia developed. This study had no control group. According to Bellantone et al.,[11] only 3/26 patients (11%) receiving an oral calcium supplement developed hypocalcaemia after TT, whereas 11/27 patients (40%) not receiving calcium supplement developed the same. Moore.[9] showed that oral calcium administration may lead to an earlier discharge without the development of hypocalcaemia.

The role of routine calcium supplements in the prevention of hypocalcaemia after TT was evaluated in recent studies.[10],[12] Malik et al. reported hypocalcaemia after TT in 3/46 (6.5%) patients in patients receiving pre-operative supplementation as compared to 12/46 in those not receiving the same (26.1%).[12] There was a statistically significant difference between the two groups (P = 0.011). Two points of our study differ from theirs. First, pre-operative supplementation in their case was a single-dose Vitamin D (2,00,000 IU) and calcium (1 g) given 24 h pre-operatively. Second, they have defined hypocalcaemia only biochemically.

A study by Jaan et al.[10] is more similar to the present study in terms of dosing of pre-operative calcium and post-operative assessment. 3/30 receiving pre-operative supplementation and 12/30 patients not receiving the same developed symptomatic hypocalcaemia (P < 0.01). Laboratory hypocalcaemia within post-operative 24 h was comparable between the two groups, but more patients of those not receiving the pre-operative supplementation compared to those who received developed hypocalcaemia at 48 h (6 and 13, respectively; P = 0.04) and at 72 h after surgery (5 and 14, respectively; P = 0.01). Intravenous calcium was given to 4/30 patients who developed tetany among those receiving pre-operative supplementation and 12/30 patients not receiving the same. Their prevalence of biochemical hypocalcaemia was 25% and clinical was about 40%, which is comparable to our study.


  Conclusions Top


It is concluded that post-operative hypocalcaemia which manifested as signs and symptoms and correlated with biochemical values was lower after receiving the pre-operative oral calcium and vitamin D3 supplement for a duration of 7 days. The intervention had most significance at 6 h both clinically and biochemically. The need of post-operative calcium supplementation both IV bolus and oral dosing was lower in the intervention group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hammad A, Modaber AA, Aliyev V. Parathyroid gland injuries during total and subtotal thyroidectomy. Clin Surg 2018;3:1931.  Back to cited text no. 1
    
2.
Nair CG, Babu MJ, Menon R, Jacob P. Hypocalcaemia following total thyroidectomy: An analysis of 806 patients. Indian J Endocrinol Metab 2013;17:298-303.  Back to cited text no. 2
    
3.
Baldassarre RL, Chang DC, Brumund KT, Bouvet M. Predictors of hypocalcemia after thyroidectomy: Results from the nationwide inpatient sample. ISRN Surg 2012;2012:7.  Back to cited text no. 3
    
4.
Hermann M, Ott J, Promberger R, Kober F, Karik M, Freissmuth M. Kinetics of serum parathyroid hormone during and after thyroid surgery. Br J Surg 2008;95:1480-7.  Back to cited text no. 4
    
5.
Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: Prospective multicenter study in Germany. World J Surg 2000;24:1335-41.  Back to cited text no. 5
    
6.
Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: A multivariate analysis of 5846 consecutive patients. Surgery 2003;133:180-5. https://doi.org/10.3978/j.issn.2305-5839.2015.08.20.  Back to cited text no. 6
    
7.
Zhu J, Tian W, Xu Z, Jiang K, Sun H, Wang P, et al. Expert consensus statement on parathyroid protection in thyroidectomy. Annals of translational medicine, 3, 230. https://doi.org/10.3978/j.issn.2305-5839.2015.08.20  Back to cited text no. 7
    
8.
Malabanan A, Veronikis IE, Holick MF. Redefining Vitamin D insufficiency. Lancet 1998;351:805-6.  Back to cited text no. 8
    
9.
Moore FD Jr. Oral calcium supplements to enhance early hospital discharge after bilateral surgical treatment of the thyroid gland or exploration of the parathyroid glands. J Am Coll Surg 1994;178:11-6.  Back to cited text no. 9
    
10.
Jaan S, Sehgal A, Wani RA, Wani MA, Wani KA, Laway BA. Usefulness of pre- and post-operative calcium and Vitamin D supplementation in prevention of hypocalcemia after total thyroidectomy: A randomized controlled trial. Indian J Endocr Metab 2017;21:51-5.  Back to cited text no. 10
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11.
Bellantone R, Lombardi CP, Raffaelli M, Boscherini M, Alesina PF, De Crea C, et al. Is routine supplementation therapy (calcium and Vitamin D) useful after total thyroidectomy? Surgery 2002;132:1109-12.  Back to cited text no. 11
    
12.
Malik MZ, Mirza AA, Farooqi SA, Chaudhary NA, Waqar M, Bhatti HW. Role of preoperative administration of Vitamin D and calcium in postoperative transient hypocalcemia after total thyroidectomy. Cureus 2019;11:e4579.  Back to cited text no. 12
    
13.
Sousa Ade A, Salles JM, Soares JM, Moraes GM, Carvalho JR, Savassi-Rocha PR. Predictors factors for post-thyroidectomy hypocalcaemia. Rev Col Bras Cir 2012;39:476-82.  Back to cited text no. 13
    
14.
Puzziello A, Rosato L, Innaro N, Orlando G, Avenia N, Perigli G, et al. Hypocalcemia following thyroid surgery: Incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients. Endocrine 2014;47:537-42.  Back to cited text no. 14
    
15.
Lo CY, Luk JM, Tam SC. Applicability of intraoperative parathyroid hormone assay during thyroidectomy. Ann Surg 2002;236:564-9.  Back to cited text no. 15
    
16.
Docimo G, Tolone S, Pasquali D, Conzo G, D'Alessandro A, Casalino G, Gili S, Brusciano L, Gubitosi A, Del Genio G, Ruggiero R, Docimo L. Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy. G Chir. 2012 Nov-Dec;33:374-8.  Back to cited text no. 16
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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