Anesthesia type



Neuromonitoring ETT

Lines and access



Standard 5-lead ECG Temperature Neuromonitoring

Primary anesthetic considerations

Relaxation with remifentanil if neuro monitoring


Hypocalcemia Recurrent laryngeal nerve palsy

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A parathyroidectomy is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies.

Preoperative management

Patient evaluation

System Considerations
Neurologic Hypercalcemia can cause altered mental status, weakness, myalgia, and rarely seizures
Cardiovascular Hypertension and tachycardia are common
Pulmonary Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin)
Gastrointestinal Hypercalcemia can cause constipation, nausea/vomiting
Renal Hypercalcemia can cause polyuria/polydipsia resulting in other electrolyte abnormalities. Also increased risk for nephrolithiasis

Labs and studies

  • EKG
  • CBC
  • BMP to evaluate calcium, magnesium, phosphate,

Operating room setup

Patient preparation and premedication

Patients should receive IV fluids and diuresis to control calcium levels.

Radioactive tracers such as methylene blue or technetium Sestamibi may be administered preoperatively to facilitate detection of parathyroid glands intraoperatively.

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

  • Intraoperative nerve monitoring (IONM) is used by surgeon to avoid injury to recurrent laryngeal nerve

Induction and airway management

  • NIMS endotracheal tube is used for recurrent laryngeal nerve monitoring
  • Preferably use video laryngoscope so surgery team can confirm lead placement


  • Supine
  • Shoulder roll

Maintenance and surgical considerations

  • Avoid paralytic for nerve monitoring. Consider remifentanil instead.


  • Ensure smooth emergence with minimal coughing/bucking, as this can cause neck bleeding
    • Consider leaving remifentanil on (around 0.05 mcg/kg/min) or extubating deep.

Postoperative management


Regular calcium levels to evaluate for postoperative hypocalcemia, which can occur in up to 15% of patients.

Pain management

Potential complications

  • Symptomatic hypocalcemia
  • Neck hematoma is rare but can develop rapidly, resulting airway compromise. Thus it is a surgical emergency requiring prompt takeback.
  • Recurrent laryngeal nerve injury, if unilateral, results in a hoarse voice, but if bilateral, can result in obstructed airway requiring emergent tracheostomy

Procedure variants

Variant 1 Variant 2
Unique considerations
Surgical time
Postoperative disposition
Pain management
Potential complications