Coerper S, Dehnel J, Stengl W
Klinik für Allgemein- und Visceralchirurgie, Referenzzentrum für Schilddrüsen- und Nebenschilddrüsenchirurgie, Krankenhaus Martha-Maria, Stadenstraße 58, 90491, Nürnberg, Deutschland.
Chirurg. 2018 Nov;89(11):909-916. doi: 10.1007/s00104-018-0631-4.
Treatment of hypocalcemia after thyroidectomy consists of an individual substitution, prophylaxis or a daily administration of calcium/vitamin D3.
Does prophylactic therapy combined with a risk-adapted substitution of calcium and vitamin D3 reduce symptomatic hypocalcemia compared to individual substitution?
After implementation of a new algorithm, patient data were prospectively documented and analyzed compared to a historical patient population. The algorithm consisted of a single prophylactic i. v. administration of calcium (1 g calcium gluconate 10% in 250 ml saline) and a risk-adapted oral administration of calcium and vitamin D3 after surgery. Patients without risk (parathyroid hormone, PTH > 15 pg/ml) were not treated. Patients with a low risk (PTH ≥ 6 ≤ 15 pg/ml and Ca > 2.0 mmol/l) received 3 g calcium, patients with a high risk (PTH ≥ 6 ≤ 15 pg/ml and Ca < 2.0 mmol/l) received 3 g calcium and 2 × 0.5 µg vitamin D3 and patients with a very high risk (PTH < 6 pg/ml) got 4 g calcium and 2 × 0.5 µg vitamin D3.
In this study 415 patients were included (230 prospectively and 185 retrospectively). Serum calcium of patients with individual substitution increased significantly at day 1 (p = 0.0001) and the number of patients with critical hypocalcemia (Ca < 2.0 mmol/l) decreased by half (27% vs. 12.2%; p = 0.0001). There was a significantly lower rate of symptomatic patients (24.9% vs 13.0%; p = 0.002) and a clear reduction of patients with a prolonged hospitalization (10.8% vs. 6.5%; p = 0.08). The rate of permanent hypocalcemia was comparable (2.2% vs. 2.1%). In the risk groups there was a significantly different rate of hypocalcemia: patients without risk (n = 170) in 2.2%, patients with low risk (n = 36) in 25%, patients with high risk (n = 13) in 69.2% and patients with very high risk (n = 11) in 71%.
This new treatment regimen is practicable, significantly lowers the symptoms, also in comparison to the literature and shows a clear differentiation between the risk groups.
甲状腺切除术后低钙血症的治疗包括个体化替代治疗、预防性治疗或每日补充钙/维生素D3。
与个体化替代治疗相比，预防性治疗联合根据风险调整的钙和维生素D3替代治疗是否能降低症状性低钙血症的发生率？
在实施一种新算法后，与历史患者群体相比，对患者数据进行前瞻性记录和分析。该算法包括单次预防性静脉注射钙（1g 10%葡萄糖酸钙加入250ml生理盐水中）以及术后根据风险调整的钙和维生素D3口服给药。无风险患者（甲状旁腺激素，PTH＞15pg/ml）不进行治疗。低风险患者（PTH≥6≤15pg/ml且Ca＞2.0mmol/l）给予3g钙，高风险患者（PTH≥6≤15pg/ml且Ca＜2.0mmol/l）给予3g钙和2×0.5μg维生素D3，极高风险患者（PTH＜6pg/ml）给予4g钙和2×0.5μg维生素D3。
本研究纳入415例患者（前瞻性纳入230例，回顾性纳入185例）。个体化替代治疗患者的血清钙在第1天显著升高（p = 0.0001），严重低钙血症（Ca＜2.0mmol/l）患者数量减少一半（27%对12.2%；p = 0.0001）。有症状患者的比例显著降低（24.9%对13.0%；p = 0.002），住院时间延长的患者明显减少（10.8%对6.5%；p = 0.08）。永久性低钙血症的发生率相当（2.2%对2.1%）。在各风险组中，低钙血症的发生率有显著差异：无风险患者（n = 170）为2.2%，低风险患者（n = 36）为25%，高风险患者（n = 13）为69.2%，极高风险患者（n = 11）为71%。
这种新的治疗方案切实可行，与文献报道相比，能显著减轻症状，且在风险组之间有明显区分。
