Underreported variation in parathyroid hormone (PTH) assays exists. Using quality improvement methods, we aimed to develop an institution-specific PTH-based protocol to predict hypocalcemia after thyroidectomy.We retrospectively reviewed patients who underwent total/completion thyroidectomy. A receiver operating curve (ROC) determined postoperative PTH cut-offs predictive of hypocalcemia. The stakeholders developed PTH-driven calcium management guidelines. Post-implementation outcomes were prospectively measured.Pre-implementation, 95 patients were assessed. PTH ≤1.5 pmol/L (14.1 pg/ml) predicted hypocalcemia (96%sensitivity), and ≥2.8 pmol/L (26.4 pg/ml) predicted normocalcemia (99%specificity) (area under curve = 0.97, SEM = 0.018). PTH on the day of and morning after surgery were identically predictive. Post-implementation, 64 patients were assessed. Hypocalcemia occurred with PTH >2.8 pmol/L in 2 cases (3.1%). Calcium over-prescribing decreased from 13.7% to 3.1% (p = 0.06). Length of stay (LOS) > 2 nights decreased from 13% to 3.1% (p = 0.05).A PTH-driven calcium management protocol post-thyroidectomy effectively reduces unnecessary calcium replacement and LOS. Given the variability in PTH assays, each institution may need to use individual cut-offs.
Image-guided surgery of the paranasal sinuses has become a valuable tool in endoscopic sinus surgery. Optical image-guided systems using infrared tracking technology are widely used. We present our experience with new angulated, hand-activated, wireless instruments in an optical tracking system for endoscopic sinus surgery.Case series.Community university teaching hospital.Sixty-five consecutive patients underwent computer-assisted endoscopic sinus surgery using a Stryker Navigation System (Stryker Canada LP, Burlington, ON). Patients underwent preoperative fine-cut axial computed tomography. At the time of surgery, anatomic fiducials were registered and the measured fiducial registration error (FRE), which is an indicator of the accuracy of the optical system, was recorded. Angulated battery-powered active instrumentation was used during the surgery.FRE, the number of anatomic fiducials used, complication rates pre- and postuse of computer-assisted sinus surgery.The mean FRE was 2.02 +/- 0.48 mm. The mean number of anatomic fiducials used for registration was 5.98. There were no major orbital or intracranial complications. Use of angulated instruments rarely caused a line of sight problem.The new optical system has a measured FRE comparable to that of other image guidance systems. Our clinical experience shows that the instrumentation decreases the "line of sight" problem and is easy to navigate and manipulate without a wire attachment to the main computer.
A detailed analysis of early complications resulting from tracheostomy in 50 consecutive patients, admitted to the Intensive Care Unit, who had required ototracheal intubation, is presented. The very low incidence of complications seen in this study supports the contention that a carefully performed tracheostomy is a safe procedure in the management of these critically ill patients. In view of this and the greater incidence of laryngeal and tracheal stenosis associated with longer periods of orotracheal intubation followed by tracheostomy, early tracheostomy should be considered in patients intubated for five days in whom further prolonged respiratory assistance is anticipated.
