Editing Thyroidectomy (section)

== '''Post-op:''' ==

=== '''Thyroid     supplementation''' ===

** Benign disease
*** 1.6mcg/kg levothyroxine       daily
**** If >65yo get lower dose
**** Round to nearest 25microg
*** Check TSH 6/52 post-op and       adjust thyroxine to keep TSH in normal range
*** Then annual TSH levels
*** For hemithyroidectomy for       benign disease, don't start anything, but check TSH  6/52 post-op. Might need some.
** Malignant disease
*** Depends on stage of       disease, aggressiveness of cancer, and need for RAI
*** If starting RAI within       2-3/52: discharge home without thyroxine
*** If not starting RAI, give       liothyronine (T3) 10-25mcg BD, then discontinue that 1-2/52 prior to RAI
*** After RAI, maintain on       levothyroxine at 1.6mcg/kg daily

=== '''Calcium/calcitriol'''     (based on Monash     Health guidelines) ===

** Relevant medications
*** Calcium given as calcium       carbonate (Caltrate, which comes in 600mg tablets)
**** If taking PPI or have had        gastric bypass, could use calcium citrate instead, as it is absorbed        better in low-acid environments, although the difference is probably        not that much
**** Hypocalcaemia symptoms -        paraesthesiae of fingertips and perioral, progressing to frank tetany        and respiratory compromise
*** Calcitriol (vitamin D3)
**** Give if very low or        undetectable PTH levels
**** Austin strategy seems to        be to give it whenever you give calcium
**** However the textbook        guidance seems to be that it is only necessary at higher doses of        caltrate
** Typical plan for an      operation where all four glands may have been compromised
*** Commence Caltrate 1.2g BD       immediately post-op
*** Measure PTH 1 hour post-op       and calcium the next morning
**** PTH >1.6pmol/L and        corrected calcium >2mmol/L: discharge
**** PTH 0.6-1.6pmol/L: monitor        with BD serum calcium. Discharge day 2 if corrected calcium stays        >2mmol/L; otherwise need to start Calcitriol 0.5microg BD and        increase Caltrate to 1.2g TDS.
**** PTH <0.6pmol/L:        Commence Caltrate 1.2g TDS and Calcitriol 0.5microg BD and monitor        calcium BD. Discharge on day 2 if corrected calcium remains        >2mmol/L.
**** If corrected calcium is        <2mmol/L, either add more oral supplements or IV calcium gluconate.
*** Ongoing need for calcium:
**** If just on Caltrate:
***** Recheck calcium at one         week. If >2mmol/L, reduce to Caltrate 600mg BD.
***** If calcium stays         >2mmol/L at two weeks, reduce to 600mg Caltrate daily.
***** If calcium is normal the         next week, cease Caltrate.
**** If on Caltrate and        calcitriol:
***** Recheck calcium at one         week. If calcium >2mmol/L, reduce to Caltrate 1.2g BD and         calcitriol 0.25microg BD.
***** At two weeks, if calcium         is >2mmol/L, reduce to Caltrate 600mg BD and calcitriol 0.25microg         daily.
***** At three weeks, if         calcium is >2mmol/L, reduce to Caltrate 600mg daily and cease         calcitriol.
***** At four weeks, if calcium         is >2mmol/L, cease Caltrate.