**5. Duration of hospital stay**

In our study, the duration of post-operative hospital stay of Group A (5.0 ± 1.1 days) (mean ± SD) was significantly shorter than that of Group B (6.4 ± 2.5 days, *p* < 0.001). The duration of post-operative stay in our series was shorter than that reported previously: 7.8 ± 2.9 days (mild hypocalcemia) versus 9.3 ± 3.9 days (severe hypocalcemia) according to Yang et al. [14] and 10.2 ± 2.3 days (mild hypocalcemia) versus 15.6 ± 6.6 days (severe hypocalcemia) according to Ho et al. [15]. It was obvious that the duration of post-operative stay in our series was 3–5 days shorter than that from previous reports of severe hypocalcemia, suggesting that the clinical algorithm we adopted was acceptable.

**107**

*Severe Hypocalcemia after Total Parathyroidectomy Plus Autotransplantation for Secondary…*

Bloody stool 1 (27) Sepsis 1 (19)

Hypocalcemia [gastritis] 1 (3) [Combined with heart failure] 1 (2) Cellulitis [lower extremity] 1 (4)

*3 months after parathyroidectomy, no one needs calcium carbonate more than 2 g/daily or calcitriol more than 0.5* 

**(Post-Op days)**

**Severe hypocalcemia (Post-Op days)**

A total of 2756 parathyroidectomy procedures were performed in patients with

Post-parathyroidectomy readmission rates for patients with CKD are five times higher than those for general population [32]. Using routing AT in our series, we found that seven patients (2.1%) underwent readmission due to various causes, and only two of them were due to hypocalcemia. One patient was readmitted 3 days after discharge due to gastritis, and the other at 2 days due to hypocalcemia and heart failure. However, no mortality was observed in our series (**Table 5**).

After successful TPX & BT plus AT for secondary hyperparathyroidism, severe

hypocalcemia occurred in 23.3% of patients in our series. The risk factors for severe hypocalcemia were young age, low preoperative Ca levels, high preoperative Alk-ptase levels, and long operation time. Serum Ca levels <7.6 mg/dL at 18 h post-operation were the optimal cutoff value for hypocalcemia that needed i.v. Ca gluconate. When the suggested clinical algorithm was followed, the mean duration of post-operative hospital stay due to severe hypocalcemia was short (6.4 ± 2.5 days)

and readmission rate (0.62%) due to hypocalcemia was quite low.

CKD, with unplanned readmission rate of 17.2 and 6.8% due to hypocalcemia/ hungry bone syndrome. In one study, readmission occurred within 30 days after discharge, but readmission for severe hypocalcemia peaked within just 10 days and

*DOI: http://dx.doi.org/10.5772/intechopen.92976*

**Causes Mild hypocalcemia**

Pancreatitis 1 (24)

Brain infarction 1 (30)

*Causes of readmission within one month post operation (Post-Op).*

**6. Readmission rate**

*μg/day to keep calcium levels over 8.0 mg/dL.*

*No surgical mortality.*

**Table 5.**

decreased thereafter [32].

**7. Conclusions**

*Severe Hypocalcemia after Total Parathyroidectomy Plus Autotransplantation for Secondary… DOI: http://dx.doi.org/10.5772/intechopen.92976*


*No surgical mortality.*

*3 months after parathyroidectomy, no one needs calcium carbonate more than 2 g/daily or calcitriol more than 0.5 μg/day to keep calcium levels over 8.0 mg/dL.*

#### **Table 5.**

*Mineral Deficiencies - Electrolyte Disturbances, Genes, Diet and Disease Interface*

levels were then checked as usual and treated accordingly (**Figure 2**).

kept in hospitalization and treated as per the clinical algorithm (**Figure 2**). Following the clinical algorithm post-operatively, we administrate i.v. Ca gluconate 4–6 g in 75 mL D5W or normal saline in 24 h for patients with Ca levels <7.6 mg/dL, Ca gluconate 8 g/day in 150 mL D5W or normal saline in 24 h for patients with Ca levels <6.5 mg/dL, and i.v. Ca gluconate 2 g/15 mL D5W or normal saline in 15 min for patients with symptoms and signs of hypocalcemia. More concentrated solution for continuous infusion should be infused via central line [29]. Either 10% Ca gluconate (40 mg of elemental calcium per 10 mL) or 10% Ca chloride (270 mg of elemental calcium per 10 mL) can be used to prepare the infusion solution. Ca gluconate is preferred because it causes less tissue necrosis if extravasated [30]. The amount of i.v. Ca gluconate is adjusted by serum Ca levels

and duration (days), neither by patients' body weight nor i.v. speed.

The K/DOQI guidelines and others suggest that serum Ca levels should be measured every 4–6 h post-operation [27, 31], but according to our experience and some other authors [28], this is not necessary except when Ca levels are <6.0 mg/dL. In such cases, we measured Ca levels every 12 h, until they were stable and reached

In our study, the duration of post-operative hospital stay of Group A (5.0 ± 1.1 days) (mean ± SD) was significantly shorter than that of Group B (6.4 ± 2.5 days, *p* < 0.001). The duration of post-operative stay in our series was shorter than that reported previously: 7.8 ± 2.9 days (mild hypocalcemia) versus 9.3 ± 3.9 days (severe hypocalcemia) according to Yang et al. [14] and 10.2 ± 2.3 days (mild hypocalcemia) versus 15.6 ± 6.6 days (severe hypocalcemia) according to Ho et al. [15]. It was obvious that the duration of post-operative stay in our series was 3–5 days shorter than that from previous reports of severe hypocalcemia, suggesting

that the clinical algorithm we adopted was acceptable.

were above the normal lower limit (2.4 mg/dL).

2 μg/day; Ca levels were checked daily.

alternate days.

At 18 h post-operation, Ca, P, and iPTH levels were checked to ensure that the operation had been successful and the levels of iPTH were < 72 pg/mL and P levels

If serum Ca levels were > 7.6 mg/dL at 18 h post-operation, oral Ca carbonate 2–4 g/day and calcitriol 0.5–1 μg/day were administered; Ca levels were checked on

If serum Ca levels were ≤7.6 mg/dL and >6.5 mg/dL at 18 h post-operation, i.v. Ca gluconate (10%) 4–6 g in 75 mL of 5% glucose in water (D5W) or normal saline was administered for 24 h, concomitant with oral Ca carbonate 4–6 g/day and calcitriol

If serum Ca levels were ≤6.5 mg/dL at 18 h post-operation, i.v. Ca gluconate 8 g in 150 mL D5W was administered for 24 h, concomitant with oral Ca carbonate 6–8 g/day and calcitriol 4 μg/day; Ca levels were checked daily except Ca levels <6.0 mg/dL. In that situation, Ca levels were checked every 12 h until they reached levels ≥6.0 mg/dL. If patients had symptoms and signs of hypocalcemia, such as paresthesia of the mouth and extremities, muscle spasms, Chvostek's sign, Trousseau's sign, seizure, tetany, EKG abnormalities, arrhythmia, and hypotension, Ca levels were checked immediately and i.v. Ca gluconate 2 g in 15 mL D5W was administered in 15 min; Ca

At 5–7 days post-operation, if patients' Ca levels were > 7.6 mg/dL, they were discharged with oral calcium carbonate 2–4 g/day and calcitriol 0.5–2 μg/day. If Ca levels were stable and ≥ 6.5 mg/dL, they were discharged with oral Ca carbonate 6–8 g/day and calcitriol 4 μg/day. If Ca levels were < 6.5 mg/dL, they were

**106**

≥6.0 mg/dL.

**5. Duration of hospital stay**

*Causes of readmission within one month post operation (Post-Op).*

## **6. Readmission rate**

A total of 2756 parathyroidectomy procedures were performed in patients with CKD, with unplanned readmission rate of 17.2 and 6.8% due to hypocalcemia/ hungry bone syndrome. In one study, readmission occurred within 30 days after discharge, but readmission for severe hypocalcemia peaked within just 10 days and decreased thereafter [32].

Post-parathyroidectomy readmission rates for patients with CKD are five times higher than those for general population [32]. Using routing AT in our series, we found that seven patients (2.1%) underwent readmission due to various causes, and only two of them were due to hypocalcemia. One patient was readmitted 3 days after discharge due to gastritis, and the other at 2 days due to hypocalcemia and heart failure. However, no mortality was observed in our series (**Table 5**).
