Does propofol anesthesia affect intraoperative parathyroid hormone levels? A randomized, prospective trial

doi:10.1016/j.surg.2004.05.059

Surgery

Volume 136, Issue 6, December 2004, Pages 1138-1142

https://doi.org/10.1016/j.surg.2004.05.059 Get rights and content

Background

Intravenous propofol (2,6-diisopropylphenol) infusion is used commonly for sedation/anesthesia during operations. Several authors have reported that propofol can interfere with intact parathyroid hormone (PTH) testing in vitro. Therefore, many surgeons avoid propofol during parathyroidectomy.

Methods

To determine whether propofol affects intraoperative PTH levels in vivo, we randomly assigned 34 patients (80% power; α < .05) with secondary hyperparathyroidism to undergo surgery for dialysis access. Patients were assigned randomly to local anesthesia with either propofol (n = 17 patients) or midazolam (n = 17 patients) sedation. PTH values were obtained before the procedure and at 10 minutes and 30 minutes after the start of the propofol or midazolam.

Results

Median preoperative serum PTH and calcium levels were 175 pg/mL (range, 27-2646 pg/mL) and 9.2 mg/dL (range, 8.1-10.8 mg/dL), respectively. There was no statistically significant difference between the PTH levels in the 2 groups at each of our time points. There was also no difference in the percentage of change from baseline in the PTH values between our 2 groups. No patient in either group had a sustained drop in their PTH level of greater than 50%.

Conclusions

Intravenous propofol infusion does not alter PTH levels significantly during the operation. Therefore, we believe the intraoperative PTH assay can be used safely during propofol sedation when parathyroid surgical procedures are being performed.

Section snippets

Methods

To determine whether propofol affects intraoperative PTH testing, we performed a randomized, single-center, prospective clinical trial on patients with secondary hyperparathyroidism who underwent a non-parathyroid operation. In this trial, we randomly assigned patients to receive propofol or non-propofol anesthesia and tested PTH levels during the operation.

Results

Thirty-seven patients were enrolled and assigned randomly to groups in the study. Three patients were unable to complete the study after randomization and were excluded from the data analysis. One patient required emergent intubation and conversion to general anesthesia; one case was performed emergently and laboratory results were not obtained, and in the third case we were unable to draw blood from the patient. The remaining samples for 34 patients were analyzed, and 17 patients were assigned

Discussion

The intraoperative PTH assay has changed the way that we approach and treat patients with parathyroid disease. Initially described for its application in single-gland disease, it has now been applied successfully to all types of parathyroid surgery.1., 3., 4. The reliability of the assay is the cornerstone of its clinical usefulness. To maintain the 95% cure rates that were seen with a bilateral exploratory procedure,6., 7. it is imperative that the assay be accurate and reliable.

Propofol

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Cited by (28)

Minimally Invasive Video-Assisted Parathyroidectomy
2021, Surgery of the Thyroid and Parathyroid Glands
Bilateral neck exploration (BNE), with the identification of at least four parathyroid glands and the removal of pathologic parathyroid tissue, has represented, for several decades, the standard of treatment of primary hyperparathyroidism (PHPT). During the past three decades, the improved preoperative localization studies and the introduction in the clinical practice of intraoperative parathyroid hormone (PTH) assay have led to development of the target approaches of the parathyroidectomy. Minimally invasive parathyroidectomy (MIP) encompasses several techniques, including approaches that use the endoscope, such as minimally invasive video-assisted parathyroidectomy (MIVAP). MIVAP was first described by Miccoli et al. Early after its first description, this technique encountered large, worldwide acceptance because it is easy to reproduce in different surgical settings. This procedure has the advantages not only for the targeted approach but also of endoscopic magnification with the theoretical lowered risk of complications because of better view of the neck structures. MIVAP gained a large worldwide acceptance in different surgical settings because of its reproducibility and its similarity with the conventional technique for the parathyroidectomy.
Intraoperative parathormone spikes during parathyroidectomy may be associated with multiglandular disease
2018, Surgery (United States)
Citation Excerpt :
One proposed mechanism for these spikes is an acute increase in parathormone secretion stimulated by the catecholamine surge induced during the induction phase of general anesthesia.15 Propofol has also been suggested to increase parathormone levels and/or interfere with parathormone assays, but prospective randomized trials have found that propofol as an induction agent does not alter parathormone levels during parathyroidectomy.16,17 The prevailing hypothesis for the spikes is mechanical stimulation of abnormal parathyroid glands, which stimulates acute parathormone secretion and thus results in these spikes.9
The importance of intraoperative parathormone “spikes” during parathyroidectomy remains unclear. This study compared patients with and without intraoperative parathormone spikes during parathyroidectomy using the criterion of a > 50% parathormone and determined the effect of intraoperative parathormone spikes on operative outcome.
We performed a retrospective review of prospectively collected data on 683 patients who underwent parathyroidectomy guided by intraoperative parathormone monitoring. An intraoperative parathormone “spike value” was calculated by subtracting the preincision intraoperative parathormone value from the pre-excision intraoperative parathormone value (SV = PE − PI). An intraoperative parathormone spike was defined as having a positive spike value ≥9 pg/mL (≥10th percentile of all spike values).
Of 683 patients, 224 (33%) had intraoperative parathormone spikes and a greater rate of multiglandular disease (8% vs. 3%, P < 0.05) and bilateral neck exploration (10% vs. 5%, P < 0.05) compared with patients without intraoperative parathormone spikes. Overall, there were no differences between parathyroidectomy patients with and without intraoperative parathormone spikes in terms of operative success (98.2% vs. 98.0%), failure (1.8% vs. 2.0%), or recurrence rates (0.4% vs. 1.3%).
Although the presence of intraoperative parathormone spikes may increase suspicion for multiglandular disease, the ability of intraoperative parathormone monitoring to predict operative success after parathyroidectomy is not affected by spikes.
Parathyroid surgery
2018, Encyclopedia of Endocrine Diseases
The surgical management of parathyroid disease has evolved with the help of several technical advances. Improved preoperative imaging studies, radioguided surgery, and intraoperative parathyroid hormone monitoring have led the current era of minimally invasive parathyroidectomy (MIP). Parathyroidectomy is a safe procedure that is often performed under regional anesthesia in the ambulatory setting. In this article, we review the recent advances parathyroid surgery, including preoperative localization studies, intraoperative adjuncts, and minimally invasive surgical techniques.
Evaluation of parathyroid function in presternal subcutaneous grafting after total parathyroidectomy for renal hyperparathyroidism
2007, Cirugia Espanola
En el contexto de la paratiroidectomía total (TPT) y trasplante paratiroideo (PTx) para el hiperparatiroidismo renal (RHP) evaluamos la función a largo plazo de injerto paratiroideo después de trasplante subcutáneo preesternal (SCPTx). Hipótesis: las glándulas paratiroideas están rodeadas por tejido adiposo. Por lo tanto, postulamos que la implantación subcutánea después de paratiroidectomía en el hiperparatiroidismo renal puede ser al menos tan eficaz como el implante muscular y sin sus complicaciones evolutivas.
Estudio realizado en un hospital universitario y su unidad de diálisis. Diseño: estudio prospectivo sobre la eficacia del procedimiento mediante determinación de paratirina intacta (iPTH) en una cohorte de pacientes quirúrgicos sin pérdida en el seguimiento. Pacientes e intervenciones: 35 (19 mujeres y 16 varones) fueron sometidos a TPT y SCPTx por RHP en el Departamento de Cirugía y Servicio de Nefrología, Hospital de Donostia (San Sebastián, Gipuzkoa, España), entre enero de 2002 y diciembre de 2005. El seguimiento ha variado entre 6 y 42 (media, 15,4) meses. Se evaluó la función del injerto mediante la determinación de las concentraciones plasmáticas de iPTH antes de la operación y 24 horas y 1, 3, 5, 15, 30, 60, 100, 150 y 200 semanas después. Los valores de referencia para la PTH en nuestro laboratorio fueron de 20-65 pg/ml.
Los valores medios preoperatorios ± desviación estándar de iPTH fueron de 1.245 ± 367,9 (rango, 493-2.160) pg/ml. Después de la TPT y el SCPTx, las concentraciones de iPTH llegaron a ser indetectables en todos los casos a las 24 horas. Se estableció 50 pg/ml como criterio de función adecuada de injerto paratiroideo. Los valores obtenidos fueron: 15,54 ± 10,61 (rango, 6-44) pg/ml a la semana, 57,2 ± 1,9 (rango, 43-74) pg/ml a las 5 semanas, 64,21 ± 9,73 (rango, 11,3-89) pg/ml a las 15 semanas, 75,12 ± 9,05 (rango, 24,6-104,2) pg/ml a las 30 semanas, 101,63 ± 19,85 (rango, 65-143) pg/ml a las 60 semanas, 121,63 ± 27,85 (rango, 62-179) pg/ml a las 100 semanas, 63 ± 19,85 (rango, 68-723) pg/ml a las 150 semanas y 102 ± 18,65 (rango, 68-113) pg/ml a las 200 semanas. La frecuencia de hipoparatiroidismo (concentración de iPTH en suero < 20 pg/ml con una concentración normal o baja de calcio en suero) fue 2/35 (5,71%) a la semana 60, y se recuperó para la semana 100. La recidiva relacionada con el injerto fue del 2,85% (1/35).
El trasplante subcutáneo preesternal tras paratiroidectomía total y trasplante paratiroideo para el hiperparatiroidismo renal secundario parece un método adecuado como alternativa al trasplante muscular antebraquial y para evitar sus complicaciones. Los resultados funcionales del injerto se comparan favorablemente con los datos publicados sobre otras técnicas quirúrgicas utilizadas para el tratamiento del hiperparatiroidismo renal. El seguimiento a largo plazo de la serie está en curso.
In the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous presternal transplantation (SCPTx). Hypothesis: Parathyroid glands are surrounded by fatty tissue. Therefore, we postulated that subcutaneous implantation of parathyroid tissue after TPT for RHP could be at least as effective as intramuscular grafting and would avoid the complications of the latter technique.
We performed a study in a university hospital and its dialysis unit. Design: Prospective open efficacy study of a postoperative diagnostic monitoring method of intact parathyroid hormone (iPTH) in a cohort of surgical patients without loss to follow-up. Patients and interventions: Thirtyfive patients (19 women and 16 men) underwent TPT and SCPTx for RHP at the Department of General Surgery and Department of Nephrology, Donostia Hospital, San Sebastián, Gipuzkoa, Spain, from January 2002 to December 2005. Follow-up ranged from 6 to 42 months (mean, 15.4 months). Graft function was evaluated by measurement of plasma iPTH levels before surgery and 24 hours and 1, 3, 5, 15, 30, 60, 100 and 150 weeks after surgery. Reference values for PTH in our laboratory were 20-65 pg/mL.
The mean preoperative iPTH values were 1245 ± 367.9 pg/mL (mean ± SD) (range, 493-2160). After TPT and SCPTx, iPTH levels became undetectable in all patients at 24 hours. A value of 50 pg/mL was established as the criterion for adequate parathyroid graft function. The following values were obtained: 15.54 ± 10.61 pg/mL (mean ± SD) (range, 6-44) after 1 week, 57.2 ± 1.9 pg/mL (mean ± SD) (range, 43-74) after 5 weeks, 64.21 ± 9.73 pg/mL (mean ± SD) (range, 11.3-89) after 15 weeks, 75.12 ± 9.05 pg/mL (mean ± SD) (range, 24.6-104.2) after 30 weeks, 101.63 ± 19.85 pg/mL (mean ± SD) (range, 65-143) after 60 weeks, 121.63 ± 27.85 pg/mL (mean ± SD) (range, 62-179) after 100 weeks, 63 ± 19.85 pg/mL (mean ± SD) (range, 68-723) after 150 weeks and 102 ± 18.65 pg/mL (mean ± SD) (range, 68-113) after 200 weeks. The prevalence of hypoparathyroidism (serum iPTH level of < 20 pg/mL with a normal or low serum calcium concentration) was 2 out of 35 patients (5.71%) by week 60, with recovery of normal values by week 100. Graft-related recurrence occurred in one out of 35 patients (2.85%).
SCPTx after TPT and PTx for secondary RHP is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. The functional results of TPT and SCPTx compare favorably with published data on other surgical techniques proposed for the treatment of RHP. Long-term follow-up of this series is currently being performed.
Hyperparathyroidism
2007, Decision Making in Anesthesiology
Hyperparathyroidism
2007, Decision Making in Anesthesiology: An Algorithmic Approach: Fourth Edition

View all citing articles on Scopus

: Presented at the 25th Annual Meeting of the American Association of Endocrine Surgeons, Charlottesville, Virginia, April 4-6, 2004.

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American Association of Endocrine SurgeonDoes propofol anesthesia affect intraoperative parathyroid hormone levels? A randomized, prospective trial

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Clin Anesth

Ambulatory parathyroidectomy for primary hyperparathyroidism

Arch Surg

Concise parathyroidectomy: the impact of preoperative SPECT 99mTc sestamibi scanning and intraoperative quick parathormone assay

Surgery

Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay

Surgery

Intraoperative parathyroid hormone measurement in patients with secondary hyperparathyroidism

Arch Surg

Intraoperative parathyroid hormone analysis: a study of 200 consecutive cases

Clin Chem

American Association of Endocrine Surgeon
Does propofol anesthesia affect intraoperative parathyroid hormone levels? A randomized, prospective trial