“Selective Rather Than Routine”:  Comment on “Predictable Criteria for Selective, Rather Than Routine, Calcium Supplementation Following Thyroidectomy”

Landry and colleagues¹ argue that the “routine” administration of calcium and calcitriol after a total thyroidectomy, although aimed at reducing the risk of symptomatic hypocalcemia in the setting of early hospital discharge, comes at a cost. In this era of clinical pathways, standardized protocols, published guidelines, and computerized discharge instructions, it is tempting for surgical residents to just press a computer button and send patients home with a standard package of instructions and medications. When we first attempted to introduce a policy of “routine” calcium/calcitriol supplementation into our unit following total thyroidectomy, there was a 12% readmission rate for hypercalcemia. Many of these patients developed significant nausea and vomiting, which indicated a failed strategy that came at a significant cost. Likewise, the alternative of measuring intraoperative parathyroid hormone levels also incurred significant costs. The equipment and the technician time were expensive and not widely available in many good local hospitals that currently perform total thyroidectomy safely. Comprehensive guidelines, such as those published by the Australian Endocrine Surgeons,² have a tendency to be overlooked because of their complexity. Indeed, less than 30% of our own surgical residents were found to be in compliance with these published guidelines. Landry and colleagues¹ have described a simple approach: the clinical postoperative assessment for symptoms of hypocalcemia, which is then followed by the measurement of serum calcium and parathyroid hormone levels the morning after surgery. This approach can be performed either in the hospital, if the patient stays overnight, or in an outpatient laboratory for centers that routinely discharge patients the day of surgery. When I was a medical student, this approach was called “sound clinical judgment.”