Hyperparathyroidism

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Clinical causes
Clinical manifestations
Diagnosis
Treatment
Preoperative management
Intraoperative management
Postoperative management

Clinical causes:

Primary hyperparathyroidism
-adenoma
-carcinoma
-hyperplasia of parathyroid gland
secondary hyperparathyroidism
-compensatory response to hypocalcemia due to an underlying primary disease (ex. renal disease)

Clinical manifestations:

General manifestations are due to effects of hypercalcemia.
Possible causes of hypercalcemia may include:
-hyperparathyroidism
-bone metastasis
-vitamin D intoxication
-milk alkali syndrome
-sarcoidosis

CNS: delirium, psychosis, coma

CVS: hypertension, ECG changes (ex. shortened QT interval)

GI: nausea, vomiting, ileus, pancreatitis

Renal:
-impaired concentrating abilitiy of kidneys
-hyperchloremic metabolic acidosis
-polyuria, dehydration, polydipsia
-renal stones
-renal failure

Diagnosis:

Primary hyperparathyroidism
-increased PTH with increased [Ca2+]

Secondary hyperparathyroidism
-increased PTH with decreased [Ca2+]

Treatment

Treatment (hypercalcemia from hyperparathyroidism):
-hydration with normal saline
-diuresis with furosemide goal: U/O = 200 - 300 cc/hr
may require:
-bisphonate: pamidronate 60-90 mg IV
-calcitonin 2-8 U/kg SQ

Treatment (surgical)
-removal of all four parathyroid glands
ex. for parathyroid hyperplasia
-removal of a single parathyroid gland
ex.adenoma of a single parathyroid gland

Preoperative management:

Assess volume status:
-hydration with normal saline
-diuresis with furosemide
-goal having urine output approx 200 - 300 ml/hr

Assess [Ca2+]:
-should bring [Ca2+] below 14 mg/dL , 7 mEq/L or 3.5 mmol/L
if [Ca2+] > 15 mg/dL then treat with:
-bisphonate (pamidronate 60 - 90 mg) : preferred due to prolonged duration of action
-calcitonin 2 -8 U/kg SQ

Intraoperative management:

CNS:
-may involve excitatation, agitation and psychosis if Ca2+ levels are elevated

CVS:
inc.[Ca2+] secondary to hyperparathyroidism may lead to:
-hypertension
-short QT interval
-ventricular dysrhythmias

Resp:
-avoid hypoventilation (respiratory acidosis) may further increased Ca2+ levels

NMJ:
-NMJ function may be altered therefore use caution with muscle relaxants

Postoperative management:

Similar complications/concerns with postoperative subtotal thyroidectomy
-thyroid storm
-recurent laryngeal ne

Rve palsy
-hematoma
-hypoparathyroidism
-pneumothorax