Original Research—Endocrine Surgery
Otolaryngology–
Postoperative Calcium Management in
Same-Day Discharge Thyroid and
Parathyroid Surgery
Kurt L. Nelson, MD1, Andrew M. Hinson, MD2,
Bradley R. Lawson, MD1, Derek Middleton3,
Donald L. Bodenner, MD, PhD2,4, and Brendan C. Stack Jr., MD1,4
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. To describe a safe and effective postoperative pro-
phylactic calcium regimen for same-day discharge thyroid
and parathyroid surgery.
Study Design. Case series with chart review.
Setting. Tertiary referral academic institution.
Subjects and Methods. In total, 162 adult patients who under-
went total thyroidectomy, completion thyroidectomy, unilat-
eral parathyroidectomy, parathyroidectomy with bilateral
neck exploration, or revision parathyroidectomy were identi-
fied preoperatively to be candidates for same-day discharge.
All patients in this study were successfully discharged the
same day on our standard prophylactic calcium regimen.
Results. Less than 1% (1/162) of patients re-presented to the
hospital within 30 days of surgery, and that patient was suc-
cessfully discharged from the emergency department after
negative workup for hypocalcemia. There was no significant
difference between preoperative and postoperative calcium
levels in the total/completion thyroidectomy groups (9.3 vs
9.2 mg/dL, respectively; P = .14). The average postoperative
calcium level in the parathyroid group was well within
normal limits (9.5 mg/dL), and the difference in postopera-
tive calcium levels between revision and primary parathyroi-
dectomy cases was not significantly different (P = .34).
Conclusion. The reported calcium regimen demonstrates a
safe, effective, and objective means of postoperative calcium
management in outpatient thyroid and parathyroid surgery
in appropriately selected patients.
Keywords
same-day surgery, same-day discharge, intraoperative para-
thyroid hormone, hypocalcemia, parathyroidectomy, thyroi-
dectomy, calcium management
Received October 22, 2015; revised January 12, 2016; accepted
January 20, 2016.
Head and Neck Surgery
2016, Vol. 154(5) 854–860
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599816631732
http://otojournal.org
H
ypocalcemia is a potentially serious sequela of both
total thyroid and parathyroid surgery. Operating
within the thyroid bed of the neck may cause acci-
dental removal of, local trauma to, or devascularization of
one or more of the parathyroid glands. Hypocalcemia can
occur in up to 30% of patients following total thyroidectomy, is
usually not evident until 12 to 48 hours postoperatively, and
is defined as corrected serum calcium \8.5 mg/dL or ionized
calcium \1.15 mmol/L.1,2 In parathyroid surgery, additional
causes of hypocalcemia include slow response of the remain-
ing parathyroid gland(s) due to long-term suppression from a
hyperfunctioning gland(s) and, although rare, hungry bone
syndrome.3 Of note, hungry bone syndrome can also be seen
postoperatively in total thyroidectomy, especially in the set-
ting of Grave’s disease. Hungry bone disease results from
severe bone demineralization from chronic hyperparathyroid-
ism (HPT) or Grave’s disease. Upon removal of the offend-
ing parathyroid gland(s) or the hyperfunctioning thyroid, the
bone demands return of lost calcium.
Risk factors for postoperative hypoparathyroidism include
operating surgeon experience4 reflected in low annual surgical
volumes, long total operative times, and excessive intraopera-
tive blood loss. Other risk factors include bilateral or revision
central neck surgery, surgery for thyroid malignancy, female
sex, surgery for parathyroid hyperplasia, lactation, pregnancy,
vitamin D deficiency, autoimmune thyroid disease (such as
Grave’s disease or Hashimoto’s thyroiditis), and history of gas-
tric bypass.2 At our institution, postoperative calcium manage-
ment is the same for both thyroid and parathyroid surgery and
1
Department of Otolaryngology–Head and Neck Surgery, University of
Arkansas for Medical Sciences, Little Rock, Arkansas, USA
2
Department of Geriatrics, University of Arkansas for Medical Sciences,
Little Rock, Arkansas, USA
3
College of Medicine, University of Arkansas for Medical Sciences, Little
Rock, Arkansas, USA
4
UAMS Thyroid Center, Little Rock, Arkansas, USA
Corresponding Author:
Brendan C. Stack Jr., MD, University of Arkansas for Medical Sciences
(UAMS), 4301 W. Markham St, #543, Little Rock, AR 72205, USA.
Email: bstack@uams.edu
Nelson et al
Table 1. Absolute Criteria for and Relative Hindrances to Same-Day Surgery.a
Relative Medical
Absolute Criteria Hindrances
Absence of major medical Untreated respiratory or
comorbidities cardiac disease
Proper preoperative education End-stage renal disease/need for
dialysis
Approved vicinity to hospital Pregnancy
Safe discharge environment Visual or hearing deficiency
Willing and able caretaker Neurologic or psychiatric
present after discharge disorder (ie, seizures,
depression, anxiety)
Obstructive sleep apnea
Anticoagulation status
a
Modified from ‘‘American Thyroid Association Statement on Outpatient Thyroidectomy’’ by Terris et al.7
is driven by postexcision intraoperative parathyroid hormone
(iPTH) measurements.
A recent study comparing multistate ambulatory thyroi-
dectomy readmission rates in California, Florida, Iowa, and
New York found hypocalcemia to be the most common
reason for readmission within 30 days postoperatively, fol-
lowed by hematoma/seroma/bleeding.5 A study from the
University of Wisconsin showed iPTH testing can reliably
predict patients who are at the highest risk of developing
hypocalcemia. They concluded patients with an iPTH \10
pg/mL were at highest risk and should be treated with both
calcium and calcitriol at discharge. Identifying these
patients prior to discharge and prophylactically managing
their calcium decreased the rate of emergency department
(ED) admissions for hypocalcemia from 8% to 1.8% (P =
.008), leading to significant reduction in cost.1
Echoing these findings, a study from our own institution
reviewed patients who underwent total thyroidectomy or com-
pletion thyroidectomy by a single surgeon and identified 268
cases intended for same-day discharge (SDD), defined as the
patient being discharged from the hospital prior to midnight on
the day the operation was performed. One hundred patients
(37%) were not discharged home on the same day due to mul-
tiple factors.6 Concern for high risk of hypocalcemia was the
leading barrier to SDD, accounting for 25.7% of cases that
were initially intended for SDD but instead were admitted.
These patients all had iPTH values \10 pg/mL (mean, 6.0 pg/
mL) with a mean calcium level of 8.4 mg/dL. Social and
transportation issues were the next causes of admission. All
patients successfully discharged home on the same day had
iPTH levels .10 pg/mL, and only one of those persons re-
presented to the ED for transient hypocalcemia.6
With low rates of hypocalcemia related readmission at our
institution, we wish to publish our experience with outpatient
calcium management of total/completion thyroidectomy and
parathyroidectomy cases guided by postexcision iPTH.
855
Relative Perioperative Relative Circumstantial
Hindrances Hindrances
Size and extent of goiter
Advanced malignancy Patient preference
Difficult hemostasis Lack of transportation and/or
caretaker
Difficult operation Communication obstacles
Methods
Protocol
All patients who undergo thyroid/parathyroidectomy receive
our standard iPTH protocol and must meet our criteria for
same-day discharge, which mirror the criteria for discharge in
the American Thyroid Association (ATA) statement for out-
patient thyroidectomy (Table 1).7 In addition, all patients are
reviewed on a case-by-case basis pre- and postoperatively for
other factors that would make them potentially unsafe to be
discharged home, such as medical comorbidities, pain, post-
operative nausea and vomiting, and urinary retention. Patients
who live outside of a 1-hour drive to our institution are asked
to stay at a local hotel or with family/acquaintance for the
first night postoperatively. Our standard intraoperative proto-
col consists of intravenous (IV) acetaminophen unless contra-
indicated, IV steroids,8-10 placement of shoulder roll for
adequate exposure, placement of esophageal probe, absti-
nence from long-acting paralytic agents, and use of moni-
tored endotracheal tubes. Also, the Harmonic Focus 1
Shears (Ethicon, Cincinnati, Ohio) device is used on all
cases.
The iPTH levels are then drawn both at 10 and 20 min-
utes after extirpation of the thyroid/parathyroid gland(s)
(Figure 1). The 20-minute value must be .10 pg/mL for
patients to be eligible for SDD,1,2,11 and if iPTH is \10 pg/
mL, the patient is observed for 23 hours.
Once discharged home, we adjust the dosing based on
serum calcium levels. Presence of surgical drain is not an
absolute contraindication to SDD and is infrequently used.
Levothyroxine prescription is given to all total/completion
thyroidectomy patients.
We employ a modified ‘‘parathyroid splinting’’12 technique
that aids the parathyroid glands as they recover from surgery
by maximizing enteral absorption of calcium via aggressive
supplementation of high doses of calcium in all patients.
856
Figure 1. Intraoperative parathyroid hormone (PTH) (20 minutes)
and postoperative calcium levels. Elevated PTH and normocalcemia
is reflective of vitamin D deficiency.
Depending on the patient’s iPTH level, 1,25 dihydroxy chole-
calciferol (calcitriol) may also be added (Table 2).
Patients who are observed will have a recheck of their
PTH and calcium levels on the morning of postoperative
day 1. By evaluating both the patients’ PTH and calcium on
postoperative day 1 and correlating this with the iPTH
levels, patients at risk for sustained hypocalcemia can be
identified more accurately than relying on calcium alone.13
That being said, the majority of the time, we check PTH
levels on postoperative day 1 only. We rely on calcium
levels alone until stabilization is reached in the rare patients
who stay longer than 24 hours postoperatively. Depending
on the direction of the trend, we adjust the patient’s calcium
regimen accordingly until stabilization.
Patients are educated prior to discharge to be aware of
signs and symptoms of hypocalcemia. We instruct patients
to take an additional 1000 mg of calcium if they experience
any symptoms at 15-minute intervals. If symptoms do not
resolve in 60 minutes after supplementing 4000 mg of cal-
cium, patients are instructed to call our service or go to a
local ED for evaluation. After discharge, all patients follow
up in the clinic 10 to 14 days postoperatively for evaluation
of their wound and for laboratory testing.
We have instituted a standard ‘‘8-pack’’ battery of labs
drawn preoperatively for total thyroid and parathyroid
patients and at the first postoperative visit for both parathyr-
oid and total/completion thyroidectomy patients that gives a
complete view of calcium homeostasis consisting of serum
calcium, ionized calcium, parathyroid hormone (PTH),
Table 2. Outpatient Calcium Management Protocol.
iPTH Level Calcium Carbonate
.15 pg/mL 1g BID
10-15 pg/mL 2g BID
5-10 pg/mL 2g BID
\5 pg/mL 2g BID
Abbreviations: BID, twice a day; iPTH, intraoperative parathyroid hormone.
Otolaryngology–Head and Neck Surgery 154(5)
creatinine, 25-hydroxyvitamin D, magnesium, chloride, and
phosphate. The same battery of labs is used in all of our
patients to standardize both our diagnostic and surveillance
methods (Table 3).
Conditions such as multiple-endocrine neoplasia type 1
(MEN1) can show inaccuracy in solely using the serum cal-
cium level in the diagnosis as well monitoring of calcium
postoperatively, which is why both serum and ionized cal-
cium are used in all our patients.14 In addition, ionized cal-
cium is not dependent on the patient’s nutritional status.
Creatinine and phosphate are used to evaluate calcium
homeostasis at the renal level. Vitamin D deficiency has
been reported to be up to 41.6% in the US population.15
Hypovitaminosis D is a the most common cause of second-
ary hyperparathyroidism and can complicate postoperative
hypoparathyroidism and hypocalcemia.16 Hypomagnesaemia
causes impaired release and function of PTH and, if low,
must be supplemented accordingly.2 Hyperchloremia in the
setting of borderline high PTH and calcium can aid in the
diagnosis of hyperparathyroidism, especially with a chloride
to phosphate ratio above 33.17
If the patient’s 8-pack battery is within normal limits
(especially calcium and PTH measurements) at the 10- to
14-day postoperative visit, we decrease the dose of calcium
that the patient was discharged home on by half for 1 week,
then discontinue altogether. If the patient is taking calcitriol,
we will decrease the dose of calcitriol by half and recheck
the calcium levels 1 week later. If normal, we discontinue
calcitriol and taper calcium as previously discussed. We
also supplement vitamin D deficiency at the postoperative
visit as needed with 50 international units of vitamin D
once a week.
Patients
After obtaining institutional review board (IRB) approval (IRB
protocol number 114616, ‘‘Peri-Operative Parathyroid Hormone
(PTH) Measurement for Outpatient Thyroid Surgery’’) from the
University of Arkansas for Medical Sciences, we reviewed our
database of total/completion thyroidectomies (Figure 2) and
parathyroidectomies (Figure 3) and identified patients (n =
162) who were discharged the same day from January 2013 to
April 2015 after meeting our previously mentioned standards.
This data set represents 55% (162 patients included/296 total
patients) of the senior author’s overall volume of total/comple-
tion thyroidectomy (n = 134) or parathyroidectomy (n = 162)
cases during the same time period.
Calcitriol Disposition
None Discharge
None Discharge
0.25 mcg BID Overnight observation
0.5 mcg BID Overnight observation
Nelson et al 857

Table 3. Patient Cost for ‘‘8-Pack’’ and Intraoperative Parathyroid

Hormone (PTH) Laboratory Testing.a
Test Costs (US Dollars)

Intraoperative PTH 4.10b

Intact PTH 4.10c
Ionized calcium 2.41
Serum calcium 0.51
Magnesium 4.10
Chloride 4.10
Phosphate 2.41
Creatinine 0.51
25-Hydroxyvitamin D 4.10 Figure 3. Percentage of unilateral (n = 58; 76.3%) vs bilateral neck
a exploration (n = 18; 23.7%) for parathyroid surgery (n = 76). One
Cost reflects charge for patients at the University of Arkansas for Medical
patient had parathyroid carcinoma and had a concurrent central
Sciences.
b
Run in 15 minutes. neck dissection.
c
Run in 30 minutes.

a medical necessity for admission. However, many of our

patients who undergo lateral neck dissection are admitted
because of a Medicare requirement for inpatient admission
for 2 midnights, a requirement that has also been adopted
by other third-party payers. If this were not a requirement,
many of the patients excluded from the 296 total patients
would have been candidates for SDD.

Figure 2. Diagnosis in patients undergoing total or completion
thyroidectomy (n = 86). Twelve of the 45 (26.7%) patients with
malignant thyroid disease underwent concurrent central neck
dissection.
Furthermore, we divided the parathyroid group into uni-
lateral, bilateral exploration, and revision surgery. Included
in the parathyroidectomy group were patients with parathyr-
oid adenoma (n = 71), parathyroid carcinoma (n = 1),
double adenoma (n = 2), parathyroid hyperplasia (n = 1),
and MEN syndrome (n = 1). Excluded were any patients
admitted as an inpatient or 23-hour observation, as the focus
of this study is to review the effectiveness of our SDD cri-
teria. Also excluded were all hemithyroidectomies2 as well
as any patient who did not have both pre- and postoperative
calcium measurements (n = 6). Each patient had a minimum
30-day follow-up. None of the patients in our cohort under-
went parathyroid autotransplantation.
Of note, 3 patients in the completion thyroid/total thyroi-
dectomy cohort also underwent lateral neck dissection of
levels 2 to 4 and were successfully discharged home the
same day. This is an important issue to point out because
lateral neck dissection does not objectively exclude a patient
from SDD. Patients will obviously be admitted if they have
Results
Serum calcium and parathyroid hormone levels, as well as
the rate of readmission for hypocalcemia, were reviewed in
162 total patients (Tables 4 and 5). Statistical analyses
were performed using SAS v9.3 software (SAS Institute,
Cary, North Carolina). Laboratory measurements are
expressed as the mean 6 standard deviation (SD) of the
mean. Quantitative unpaired values were compared using
the Student t test. Variables that were not normally distribu-
ted were expressed as the median value and assessed by use
of the Mann-Whitney rank-sum test for nonparametric data.
Pre- and postoperative calcium levels (drawn at the
patient’s 10- to 14-day postoperative visit) were compared
in both groups, yielding a nonsignificant P value in the thyr-
oid group (P = .14). Pre- and postoperative calcium levels
were significantly different in the parathyroid group (P \
.0001), which is expected given this is a surgery for hyper-
calcemia. However, the average postoperative calcium level
was well within the normal range in both the bilateral
exploration and unilateral exploration groups. Six parathyr-
oidectomy patients had a history of neck surgery, including
thyroidectomy or parathyroidectomy; mean (SD) postopera-
tive calcium in these patients (9.25 [0.53] mg/dL; range,
8.4-10.0 mg/dL) was not significantly (P = .34) lower than
patients undergoing unilateral or bilateral exploration.
In addition, \1% of our patients (1/162) presented to the
ED within 30 days of surgery. This patient presented to the
ED with complaints of perioral tingling. She was evaluated,
found to have normal calcium levels, and discharged from
the ED with instructions to follow up in the clinic without
858
Table 4. PTH and Calcium Values before and after Total or Completion Thyroidectomy.
PTH, pg/mL, Mean (SD)
Thyroidectomy Baseline 10 min
Total (n = 78) 66.7 (34.3) 55.8 (39.1)
Completion (n = 8) 61.2 (41.7) 53.2 (29.6)
Grand total (n = 86) 66.2 (34.8) 56.0 (38.2)
Abbreviations: PTH, parathyroid hormone; SD, standard deviation.
Table 5. PTH and Calcium Values before and after Parathyroidectomy.
PTH, pg/mL, Mean (SD)
Parathyroidectomy Baseline 10 min
Unilateral (n = 58) 123.6 (54.1) 56.2 (44.8)
Bilateral (n = 18) 116.5 (38.8) 71.6 (60.2)
Grand total (n = 76) 121.9 (50.7) 59.9 (48.9)
Abbreviations: PTH, parathyroid hormone; SD, standard deviation.
receiving IV calcium supplementation. We asked our
patients at follow-up if they presented to an outside ED, and
none reported this. In addition, nurses’ notes were reviewed
as part of this study, and we did not find any patient who
called our clinic to report that he or she presented to another
ED.
Discussion
Thyroid and parathyroid surgeries have historically been per-
formed as inpatient procedures, but over the past decade, out-
patient procedures have increased and can be done safely in
appropriately selected patients.7,18 A 2013 article reviewed
University Health Consortium (UHC) data and found that
from 2005 to 2010, the proportion of outpatient thyroid sur-
gery compared with inpatient thyroid surgery rose steadily
over that time period. In 2010, 55% of all thyroid surgery in
that cohort was performed as an outpatient surgery.19
In addition to increasing in frequency, outpatient thyroi-
dectomy has been shown to be reducing costs as well. A
study by Terris and associates20 found a mean cost of $7814
for outpatient thyroidectomy compared to $10,288 for inpa-
tient. A similar study of UHC data showed the total cost of
outpatient thyroidectomy and compared the cost of SDD
with 23-hour observation. The average cost of outpatient
thyroidectomy was $5617, with the average cost of SDD
being $4642 compared with $6101 for overnight observation
(P \ .0001).21
Another study using UHC data reported a cost reduction
in outpatient parathyroidectomy compared with inpatient
parathyroidectomy. In total, 21,057 patients underwent outpa-
tient parathyroid surgery between 2005 and 2010 with a
reported average cost of $12,738 for outpatient parathyroi-
dectomy compared to $14,657 for inpatient parathyroidect-
omy (P = .004).22 Moreover, the study also reported a higher
Otolaryngology–Head and Neck Surgery 154(5)
Calcium, mg/dL, Mean (SD)
20 min Preoperative Postoperative (Days 10-14)
55.9 (34.0) 9.3 (0.4) 9. 2 (0.5)
50.5 (34.2) 9.3 (0.2) 9.0 (0.4)
55.5 (34.7) 9.3 (0.4) 9.2 (0.5)
Calcium, mg/dL, Mean (SD)
20 min Preoperative Postoperative (Days 10-14)
44.8 (34.8) 10.5 (0.7) 9.5 (0.6)
47.1 (44.7) 10.5 (0.8) 9.5 (0.8)
37.7 (29.2) 10.5 (0.7) 9.5 (0.6)
proportion of SDD vs overnight admission in the outpatient
surgery group. This study did not report a cost comparison
between SDD and overnight admission.
Parathyroid surgery attempts to correct hypercalcemia
caused by an abnormal parathyroid gland via removal of the
offending gland(s). As a result, patients are at risk for develop-
ing hypoparathyroidism with hypocalcemia postoperatively.
However, patients who undergo single-sided parathyroid sur-
gery are at a lower risk (albeit not zero) for developing post-
operative hypoparathyroidism with hypocalcemia compared
with patients who undergo either bilateral/revision parathyroi-
dectomy or total/completion thyroidectomy. However, we
manage all of these patients the same in terms of prophylactic
calcium.
As previously stated, concern for postoperative hypopar-
athyroidism and subsequent hypocalcemia is the leading
barrier to SDD at our institution.6 Due to the unique nature
of our institution, we serve a multitude of patients who live
more than 2 to 3 hours away and may not live in close prox-
imity to another highly skilled health care facility. We
believe it is much safer to discharge these patients home on
a prophylactic calcium regimen to minimize the risk of
developing symptomatic hypocalcemia contrasted to dis-
charging these patients home without calcium supplementa-
tion. With regards to oversupplementing and creating a state
of hypercalcemia, we have not observed this to be an issue.
A 10- to 14-day postoperative follow-up is a protection for
this. Conversely, in our experience, the risk of developing
hypercalcemia from supplementation has shown to be essen-
tially zero, evidenced by an average postoperative calcium
level of 9.5 mg/dL in patients undergoing unilateral para-
thyroidectomy (Table 4).
We employ a modified ‘‘parathyroid splinting’’12 technique
to avoid postoperative hypoparathyroidism and hypocalcemia.
Nelson et al
The rationale behind this technique is based on a study by
Sitges-Serra and associates,12 who found that patients with
higher calcium levels 1 month after surgery had improved
return of native parathyroid function. The hypothesis was that
by decreasing the physiologic burden on the parathyroid
glands as they recover from transient postsurgical changes
such as injury and ischemia, they are better able to recover
and return to normal function.
Harmonic Focus 1 Shears are used on all cases in an
attempt to further decrease the rate of postoperative hypo-
calcemia. Thermal energy devices have been shown in a
meta-analysis to decrease the rate of postoperative transient
hypocalcemia as well as total operative time.23 Anecdotally,
we feel hemostasis using thermal energy devices is superior
compared with traditional techniques.
It is worth discussing why we obtain both 10- and 20-
minute iPTH levels. First, by comparing the rate of change
between the 10- and 20-minute values in both parathyroid
and thyroid surgery, we may find it necessary—if there is a
drastic change between the two levels—to obtain a third
value to ensure the iPTH level does not drop below 10 pg/
mL. On the other hand, sometimes the 10-minute level is
actually \10 pg/mL, but the 20-minute level is within the
range for SDD. In these cases, we will use the 20-minute
level as this shows the patient has parathyroid function. Also,
in parathyroid surgery, we use must ensure biochemical cure
that is based on the Miami Criterion,24 and at times this level
is not yet reached 10 minutes after extirpation of the gland.
Using 2 iPTH levels allows for analysis of a trend.
Houlton and associates25 reported similar outcomes to
our cohort in a 2011 study with no readmissions in patients
who underwent outpatient thyroidectomy using a standar-
dized protocol that used rapid PTH obtained in the posta-
nesthesia care unit (PACU) as a major determining factor
for discharge. In their series, in the absence of other factors,
patients were eligible for discharge if their PACU PTH was
.20 pg/mL. In addition, Norman and Aronson18 reported a
readmission rate of \1% following outpatient parathyroi-
dectomy in a cohort of patients who were discharged home
with prophylactic calcium supplementation.
Given the debate regarding the superiority of iPTH
(defined as PTH obtained in the operating room) vs early
postoperative PTH (PTH obtained 1-4 hours after surgery),
a meta-analysis was recently done that compared the effi-
cacy of iPTH with early postoperative PTH in patients
undergoing total thyroidectomy. Fourteen studies were
found that met inclusion criteria. Excluded were studies that
only had a hemithyroidectomy as well as studies that did
not report a PTH value or had a PTH value that did not
meet criteria as iPTH or early postoperative PTH. The
authors found that iPTH and early postoperative PTH values
were both significantly lower in hypocalcemic individuals
and that there was no statistically significant difference
between iPTH and early postoperative PTH.26 This implies
that both methods are an acceptable means to measure a
patient’s PTH level and place them on the appropriate cal-
cium regimen.
859
At our institution, the cost of iPTH and early postoperative
PTH is the same (Table 3); however, the results of iPTH
have a turnaround time of 15 minutes compared to 30 min-
utes with early postoperative PTH. In addition, we use iPTH
as part of our approach for minimally invasive radio-guided
parathyroidectomy (MIRP), and to make the operating room
as efficient as possible, we use iPTH for both MIRP and total
thyroidectomy since cost and efficacy are the same.
However, either iPTH or early postoperative PTH can be
used to assess a patient’s appropriate calcium regimen as
described earlier if a significant cost difference exists
between the 2 tests at a given institution; however, iPTH
offers cost savings in eliminating extended observation.
In addition to the requirements listed in Table 1 and the
iPTH requirement of .10 pg/mL, each patient’s discharge
from the hospital should be considered on a case-by-case
basis as to whether he or she is safe for same-day discharge.
As mentioned previously, factors such as medical comorbid-
ities, pain, postoperative nausea and vomiting, urinary reten-
tion, and so on would all be obstacles to same-day discharge.
Therefore, it is extremely vital to examine the patient prior to
discharge to assess for any of these particular issues.
Conclusion
Outpatient thyroid and parathyroid surgery is a safe and
effective procedure.7 Thirty-day representation was \1%,
consistent with literature.18,25 Our algorithm demonstrates a
safe and effective protocol for outpatient thyroid/parathyroid
surgery. Also, both iPTH and early postoperative PTH are
adequate means to manage the patient’s calcium regimen
accordingly.26 By identifying patients at high risk for devel-
oping hypocalcemia and placing all patients on an appropri-
ate calcium prophylaxis, both ED readmission rates and
hospital costs can be reduced.1,6,18-22
Author Contributions
Kurt L. Nelson, writing, editing, data gathering, approval, accounta-
ble; Andrew M. Hinson, writing, data gathering, editing, approval,
accountable; Bradley R. Lawson, content idea, data gathering, edit-
ing, writing, approval, accountable; Derek Middleton, data gathering,
editing, approval, accountable; Donald L. Bodenner, content idea,
editing, approval, accountable; Brendan C. Stack Jr., content idea,
editing, writing, approval, accountable.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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