A patient undergoing total thyroidectomy for Graves' disease develops acute hypocalcemia 6 hours postoperatively. Serum PTH level is 8 pg/mL (normal 10-65). The most appropriate initial management is:

• A IV calcium gluconate bolus followed by calcium carbonate oral supplementation
• B Oral calcium carbonate alone with close monitoring
• C Immediate re-exploration for parathyroid autotransplantation
• D IV calcium gluconate followed by continuous infusion with oral calcitriol ✓

Explanation

Acute symptomatic hypocalcemia with low PTH (hungry bone syndrome or parathyroid devascularization) requires IV calcium gluconate bolus (1-2 g over 10 minutes for tetany) followed by continuous IV calcium infusion (calcium gluconate 10-15 mg/kg/hour in 5% dextrose) combined with oral calcitriol (0.25-0.5 mcg twice daily) to bypass the 1-alpha hydroxylation step. Calcitriol is essential because parathyroid insufficiency impairs renal activation of vitamin D. Oral calcium alone is insufficient for symptomatic acute hypocalcemia. Re-exploration is not indicated for postoperative hypoparathyroidism.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.