Hyperparathyroidism

 

 

 

Background

 

  • Primary hyperparathyroidism: parathyroid adenoma or carcinoma 

  • Secondary hyperparathyroidism: an appropriate compensatory response of the parathyroid glands to counteract a disease process that produces hypocalcemia

  • Ectopic hyperparathyroidism: due to secretion of parathyroid hormone (or a substance with similar endocrine effects) by tissues other than the parathyroid glands

 

 

Considerations

 

  • Potential difficult airway: 

    • Mass effect (goitre)

    • Osteopenic bone (pathologic fractures of mandible & vertebral bodies)

  • Physiologic changes of hypercalcemia:

    • CNS: ↓LOC, hallucinations, psychosis

    • Cardiovascular: hypertension, hypovolemia, conduction blockade

      • Hypercalcemia ECG: ↑PR interval, ↓QTc 

    • Respiratory: potential respiratory muscle weakness, poor clearance of secretions

    • Renal: renal failure, nephrolithiasis (70%)

    • GI: ↑ aspiration risk, nausea/vomiting, abdominal pain, pancreatitis

    • MSK: weakness (titrate neuromuscular blockers to effect), pathologic fractures (careful positioning) 

    • Hematologic: anemia

  • Underlying etiology:

    • Parathyroid tumour, PTH-producing tumour

    • Chronic renal failure (usually associated with hypocalcemia, hyperphosphatemia)

  • Considerations of cancer & associated syndromes (MEN 1):

    • MEN 1: hyperparathyroid, pancreatic islet cell tumors, pituitary hyperplasia or tumor

    • MEN 2A: hyperparathyroid, medullary thyroid carcinoma, pheochromocytoma

  • Post-op airway obstruction after parathyroidectomy:

    • Hematoma, laryngospasm, hypocalcemia, recurrent laryngeal nerve injury, tracheomalacia

    • Mandibular fracture

 


Optimization

 

  • Management of hypercalcemia:

    • IV rehydration

    • Furosemide after IV hydration → goal is 3-5 L urine output/day

      • ​If severe, add:

        • ​Bisphosphonate (etidronate 7.5mg/kg IV OD or 20mg/kg PO OD)

        • ​​Calcitonin 200 IU nasal spray/day

        • ​​IV steroids

        • Phosphate repletion

    • Hemodialysis if life threatening hypercalcemia or acute renal failure

  • Monitor EKG & calcium concentrations perioperatively

  • Prevent pathological fractures (careful positioning) 

  • Airway vigilance postoperatively

 


Conflicts

 

  • Hypovolemia vs. RSI (ESWL or percutaneous drainage for nephrolithiasis)

  • Renal failure vs. succinylcholine for RSI

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