Pituitary Surgery: Peri-operative Management
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Pituitary Surgery:Peri-operative Management
Anna Boron, MD
Faculty physician in Endocrinology in the Department of Internal Medicine at St. Joseph’s Hospital and Medical Center
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What is the Likely Nature of the Sellar Mass?
• Pituitary adenoma• Craniopahryngioma• Meningioma• Pituitary hyperplasia• Infiltrative / infmammatory process• Infection• Apoplexy• Metastatic lesion /primary cancer
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Is There Any Compression (mass) Effect?
• Suprasellar, ”upward“ expansion – headache, visual field defects
• Lateral expansion – IV, V, VI cranial nerve palsy, headache, pituitary crisis (with apoplexy)
• Downward expansion – CSF leak, rarely blindness, temporal epilepsy
• Pituitary compression – hormonal deficiencies
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Which, if any, Hormone is Overproduced?
• Hyperprolactinemia – most frequent• GH hypersecretion - acromegaly• ACTH hypersecretion – Cushing’s disease• TSH hypersecretion - thyrotoxicosis• Gonadotropin producing tumors – so called
“nonfunctioning” pituitary tumors
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Which, if any, Hormone is Lacking?
• Functional suppression
• Physical suppression
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Peri~ and Postoperative Steroid Replacement
• In patients with known adrenal insufficiency “stress dose” of steroids is given, with postoperative taper to the home dose of steroids
• If postoperative cortisol level <10 mcg/dl, upon discharge - Rx hydrocortisone 15 mg q8am and 5 mg q2pm
• “Sick day” rule• Cosyntropin stimulation test • In Cushing’s disease – gradual taper from steroids
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Steroid Replacement
Every patient with central adrenal deficiency needs ID necklace or bracelet
Steroid supplementation:• Hydrocortisone• Prednisone• Dexamethasone
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Thyroid Replacement
• If hypothyroidism present pre-operatively, levothyroxine replacement should be started in dose 1.6 mcg/kg BW
• Thyroid function should be re-measured 6-8 weeks after dose initiated
• Therapy effectiveness should be assessed by plasma free T4
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Gonadotropins
1. Testosterone not routinely given before surgery
2. Testosterone replacement post surgery:– Depot testosterone 200 mg/ Q 2 weeks or 100 mg
weekly IM– Testosterone gel– Testosterone patch
3. Monitoring of hemoglobin and hematocrit, PSA, total testosterone level
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Gonadotropins
• Estradiol skin patches/ oral estrogen supplementation
• Progesterone supplementation in patients with intact uterus
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GH Deficiency
• GH supplementation in severe GH deficiency with stimulated GH <3 mcg/l or in patients with three or four other pituitary hormone deficiencies and low IGF-1 level
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Disorders of Water and Salt
1. Hypernatremia• Diabetes Insipidus (DI)• Fluid loss ( GI loss, insensible loss)
2. Hyponatremia• SIADH• Cerebral salt wasting• GI loss• Adrenal insufficiency/ hypothyroidism• edema
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Hypernatremia
• Plasma sodium >145 mmol/l• Relative sodium excess compared to whole body
water• Results either from net water loss or sodium load• Symptoms: weakness, confusion, seizures, coma• Complications: cerebral bleeding, permanent brain
damage and death, cerebral edema with overfast correction of hypernatremia
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Hypernatremia
• Prognosis - the mortality rate depends on the severity of the hypernatremia and the rapidity of its onset
• Severe hypernatremia - mortality rate of approximately 40-70% in elderly patients
• The level of consciousness is the single best prognostic indicator
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Diabetes Insipidus• Condition that occurs when the kidneys are unable to
conserve water as they perform their function of filtering blood
• The amount of water conserved is controlled by antidiuretic hormone (ADH)
• ADH is a hormone produced in the brain (hypothalamus), then stored and released from the pituitary gland
• Central DI - caused by a lack of ADH• Nephrogenic DI - caused by a failure of the kidneys to
respond to ADH
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Diabetes Insipidus
• Symptoms – excessive thirst, craving for ice water, excessive urine volume, dehydration
• Treatment – underlying condition should be treated when possible
• Central DI may be controlled with vasopressin (desmopressin, DDAVP), fluids
• If treated, diabetes insipidus does not cause severe problems or reduce life expectancy
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Hyponatremia
• Plasma sodium <135 mmol/l• Euvolemic hyponatremia - total body water
increases, but the body's sodium content stays the same
• Hypervolemic hyponatremia - both sodium and water content in the body increase, but the water gain is greater
• Hypovolemic hyponatremia - water and sodium are both lost from the body, but the sodium loss is greater
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Hyponatremia• Symptoms: abnormal mental status, confusion,
hallucinations, coma, seizures, fatigue, headache, muscle spasms or weakness, nausea, vomiting
• Treatment - depends on the type of hyponatremia and underlying cause and may include: fluids through a vein, medications (demeclocycline, vaptans, salt supplements), water restriction
• The outcome depends on the condition that is causing the low sodium
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