Anesthesia management for pituitary tumor
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Anesthesia management for Pituitary tumor
Dr. Abhijit Nair,
Axon Anesthesia Associates,
Consultant Anesthesiologist,
Care Hospital,
Hyderabad.
i
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Pituitary adenomas are common, 1 in 1000
Benign
Slow growing, but can invade adjacent
structures ( cavernous sinus )
Carcinomas : RARE
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Mechanism of tumor generation:
Malfunction of growth regulating genes
Abnormalities of tumor suppressor genes
Alteration in genes controlling programmed cell death
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Risk factors for developing pituitary tumors:
MEN 1
Carney complex
Isolated familial
Acromegaly
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Pituitary Gland:Master Endocrine Gland
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Cont:
2 histological entities-
Large, vascular, pink anterior lobe
or adeno hypophysis
Small, grey-white posterior lobe
or neuro hypophysis
Stats :
6mm height,
13 mm width,
9mm AP.
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Cont.Lies within pituitary fossa or sella turcica
Floor & anterior wall of sella – Roof of sphenoid sinus
Posterior wall – clivus
Lateral wall – cavernous sinus
Roof – Diaphragmatic sella
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Type of Adenoma Secretion Pathology
Corticotrophic ACTH,POMC Cushing’s syndrome
Somatotrophic GH Acromegaly
Thyrotrophic ( Rare ) TSH Hyperthyroidism(asymptomatic)
Gonadotrophic LH,FSH Asymptomatic
Lactotrophic or Prolactinomas ( most common)
Prolactin Galactorrhoea,hypogonadism, amenorrhoea, impotence, infertility
Null cell adenomas No secretion
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Classification: By nature:
1) Benign,
2) Invasive adenomas,
3) Carcinomas
By activity:
1) Non functioning,
2) functioning
By size:
1) Micro adenoma, < 1cm,
2) Macro adenoma, > 1cm
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By site of origin :
Sellar ( tumors of anterior & posterior pituitary)
Suprasellar ( craniopharyngioma, suprasellar extension of pituitary lesion )
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History:Pierre Marie, a French neurologist
in Paris was the first to describe
disease involving pituitary gland
In 1886, he studied patients
with clinical findings of what
he termed as acromegaly &
postulated that pituitary
gland was the culprit
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Presentation:
Hormonal hyper secretion syndromes: Hyperprolactinaemia,acromegaly,Cushing’s disease
Mass effect: visual disturbance or raised ICP
Non specific: infertility, headache, epilepsy, pituitary hypofunction
Incidental: Detected during imaging for other conditionsPituitary apoplexy ( rarely )
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Goals of pituitary surgery:
To remove as much as tumor
as possible to relieve compression
& to eliminate hormonally active tissue
Avoid additional neurological damage
To protect healthy pituitary tissue
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Important factors:Experience of Surgeon
Size & location of tumor
Consistency of tumor
Other variables
( vascularity, presence of
venous sinuses )
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Work up:
Basal prolactin concentration,
( 2.8-29.2 ng/ml in women,
2.1-17.7 ng/ml in males)
Growth hormone:
GH concentration:
short t1/2, misleading if done alone-
abnormal if > 10 mU/L )
Failure of GH suppression to < 2mU/L with 75 gm oral glucose,
Increased IGF-1 ( a somatomedin )
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ACTH:
Primary screening procedures-
- Urinary concentration of free cortisol,
- Loss of diurnal cortisol control,
- Lack of response to ACTH suppression
Thyroid function tests,
High quality MRI,
CT scan – for bony invasions
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Pre operative assessment:
:-Visual function
:-Signs and symptoms
of raised ICP
:-Endocrine studies,
effects of hormonal
hypersecretion
:-Co morbidities
- in acromegaly ,
Cushing’s syndrome
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Anesthetic issues :Anatomical changes:
• Prognathism and macroglossia• thickening of the pharyngeal and laryngeal soft tissues and vocal cords• reduction in the size of laryngeal aperture• hypertrophy of periepiglottic folds • Recurrent laryngeal nerve palsy • enlarged thyroid: 25%
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:- OSA
:- Hypertension
:- Glucose intolerance
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AcromegalyIncreased skull size, enlarged lower jaw
Mal occlusion of teeth
Macroglossia, prognathism, thickened
pharyngeal & laryngeal tissues
Hypertension, Cardiomegaly
Impaired LV function
Impaired Glucose tolerance
Proximal myopathy, difficult cannulation
Enlarged thyroid
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Cushing’s syndrome
Appearance
Impaired Glucose tolerance
Hypertension, ECG changes,
LVH, ASH
Hypernatremia, hypokalemia, alkalosis
OSA, GERD
Proximal myopathy
Cannulation
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Surgical approach:
Trans sphenoidal approach
- Sublabial
- Endonasal
Trans ethmoidal approach
Trans cranial
- Subfrontal
- Pterional
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Anesthetic management
Hemodynamic stability
Maintenance of cerebral
oxygenation
Facilitate surgical conditions
Prevent of intra operative
complications
Rapid emergence to facilitate
early neurological assessment
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Cont:
Airway management:
4 grades described in acromegaly:-
Grade 1 – No significant involvement
Grade 2 – Nasal & pharyngeal mucosal hypertrophy with normal glottis
Grade 3 – Glottic stenosis or VC paresis
Grade 4 – Glottic & soft tissue abnormalities
South wick JP, Katz J. Unusual airway obstruction in acromegalic patients- indications for Tracheostomy. Anesthesiology 1979; 51: 72-3.
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Cont:
Throat pack
Preparation of nasal mucosa
Lumbar drain ( in patients with significant suprasellar extension )
Position
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Maintenance:“ Personal preference”
Any technique suitable for intracranial procedures
Extra cautious in presence of raised ICP
Short acting agents
Normocapnia
RAE tube south
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Monitoring:
Standard
ABP
Filling pressures
( Cushing’s disease )
VEP ( Visual evoked potential )
PNS
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Emergence from anesthesiaSmooth and rapid
Removal of pack, pharyngeal suction
Extubation in a semi seated position
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Operative complications:False aneurysm ( Rx: endovascular / clipping )
Damage to pons ( minimised by frequent fluoroscopy )
In transcranial:
Frontal lobe ischemia- prolonged traction
Seizures ( subfrontal )
Anosmia ( olfactory tract damage )
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Post op care:
Airway management
Analgesia
Hormone replacement
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Post op hormone complications: Diabetes insipidus:
Develops within first 24 hrs
( when > 80% vasopressin
secreting neurons are destroyed
or become non functional )
Features :-
Increased Posm > 295 mosm/kg
Hypotonic urine ( < 300 mosm/kg )
Urine output > 2ml/kg/hr consistently
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Treatment
DDAVP (desmopressin acetate ) nasal/ sc
s/c Vasopressin
Monitor plasma sodium, osmolality
IVF ( maintenance + 2/3rd urine output in previous hour )
Type of fluid ( on electrolyte picture)
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Hyponatremia
Commonest cause: over enthusiastic DDAVP use
Rarely- SIADH
In SIADH : water retention,
Loss of sodium in urine
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References:
Pituitary disease & Anesthesia. M Smith & N P Hirsch. BJA 85(1) : 3-14(2000)
Treatment of Pituitary tumors : a surgical perspective. Chandler, Barkan. Endocrinal Metab Clin A Am, 37(2008) 51-66
Barash’s Clinical Anesthesia
Miller’s Anesthesia
Harrison’s Principles of Internal Medicine
Google Web & Images
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THANK YOU