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Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery

Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery. R3 김대언. 10% of diagnosed brain neoplasms TSR-20% of all intracranial op. for primary brain tumors unique challenges to anesthesiologist require multidisciplinary approach

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Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery

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  1. Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery R3 김대언

  2. 10% of diagnosed brain neoplasms • TSR-20% of all intracranial op. for primary brain tumors • unique challenges to anesthesiologist • require multidisciplinary approach • dependent on quality of perioperative care

  3. Preoperative Assessment and Related Perioperative Concerns • peak incidence during 40~60 • macroadenoma vs microadenoma : 1Cm • functioning vs nonfunctioning : related with time and size of detection • headache : m/c Sx • visual loss : temporal or bitemporal hemianopsia d/t mass effect • hypopituitarism : ant. pituitary compression • hyperprolactinemic : loss of tonic inh. of prolactin

  4. inc. ICP • directly tumor itself or indirectly from its obx. of 3rd ventricle • mannitol and lumbar intrathecal drainage • preop. laboratory evaluation • CBC : anemia, blood loss • metabolic panel : hyponatremia, hypercalcemia, hyperglycemia • hyponatremia : post. pituitary dysfunction and DI • hypercalcemia : MEN type 1 • endocrine evaluation : thyroid panel..., pregnancy test • preop. hormone replacement : d/t preop. hypopituitarism

  5. Endocrine Disease • Prolactinoma • most frequently type(20~30%) • women : amenorrhea, galactorrhea, loss of libido, infertility • men : dec. libido, impotence, premature ejaculation, erectile dysfunction, oligospermia • microadenoma : 20:1 female predominance • macroadenoma : equal • 90% response to medical Tx. - bromocriptine

  6. Acromegaly • cardiovascular and respiratory Cx. • 50% death before 50 yrs • cardiovascular • HTN, LVH • diastolic dysfunction • systolic function : preserved • RVE • return to normal size after therapy : but can be interstitial myocardial fibrosis • angina : should be alert d/t myocardial ischemia • supraventricular and ventricular ectopy, BBB • EKG : ST depression, T wave abn. conduction defect

  7. respiratory • thickening of the laryngeal and pharyngeal soft tissue • reduction in the size of the glottic opening • hypertrophy of the periepiglottic folds • calcinosis of the larynx • recurrent laryngeal n. injury : hoarseness • can cause airway obx. and respiratory dis. • secondary obx. sleep apnea and central respiratory dep. • can return to normal within 10days : vocal cord function • narcotic and benzodiazepine : should be used with extreme caution

  8. Cushing's Disease • inc. endogenous corticosteroids : cause systemic HTN • inc. CO, hepatic production of angiotensinogen • inc. influx of Na in vascular smooth m. cell • inh. of phospholipase A2 • inc. expression of the angiotensinogen II receptor and enhancement of inositol triphosphate production in vascular smooth m.cell

  9. EKG : high vol. QRS complex, inv. Twave • can revert to normal in 1yr • OSA • glucose intolerance : should treat over 180mg/dL with IV insulin • exophthalmos : should be cognizant of corneal abrasion • cannulation can be extremely difficult • myopathy : no change to susceptibility to succinylcholine or nondepolarizing drug • infection : no empiric change necessary • osteoporosis and pathologic Fx. : caution during positioning

  10. Thyrotropic(TSH-Producing) Adenoma • rare(<2.8%) • can cause pituitary hyperthyroidism • can be quite large upon diagnosis • >60% locally invasive : risk of blood loss • propylthiouracil or octreotide

  11. Nonfunctioning Tumors : Nonfunctioning Adenomas, Rathke Cleft Cyst, Craniopharyngioma • 2nd m/c type of tumor • Sx related to local mass effect • must be screened for hypopituitarism

  12. Perioperative Corticosteroid Administration • tradition : stress dose of 50~100mg hydrocortisone every 6~8hr for several days • rarely required beyond 24hrs • dexamethasone : use in Cushing's dis. d/t no interference with postop. serum cortisol assay • no adm. of cortisol and 6hr serum cortisol • rapid lab available only

  13. Intraoperative Considerations • Surgical Approach • transnasally • sublabial transseptal approach : only in extremely large or in children • endoscopic endonasal approach • fewer cosmetic, dental, nasal Cx, short recovery, less postop. DI • lumbar intrathecal catheter • inject saline or remove CSF • inject intrathecal air • push the tumor down • outline a tumor • discontinue nitrous oxide

  14. Airway Management • Cushing's dis. and acromegaly • acromegaly : routine tracheostomy advocated • large tongue and hypertrophied upper airway • difficult intubation and LMA and flexible fiberoptic laryngoscopy • should prepare alternative tool • Cushing's dis : OSA or obesity • diabetes : presence of GERD, slow empting time

  15. Positioning and Preparation for Surgery • some degree of head-up position • risk of VAE • epinephrine injection : dysrhythmias and HTN • B-blocker taking pts : HTN aggravation d/t A effect • inc. depth of anesthesia

  16. Monitoring • arterial cannulation • acromegalic pt : caution in radial artery cannulation • CVP and LVEDP, LVEDV, preroad : poor correlation in acromegalic pt • VEP : not specific d/t sensitivity to the effects of anesthetics

  17. Intraoperative Management • rapid cleared drug or anesthetics : d/t rapid emergence • propofol, remifentanil, sevoflurane • proximity of ICA : risk of hemorrhage • Cushing's dis. : difficulty in IV • prone to upper airway obx. : tracheal extubation in a seated position

  18. Postoperative Considerations • Cranial Nerve Dysfunction and CSF Leakage • cranial n. function : particular attention • rhinorrhea and fluid leakage : lab. analysis and operative repacking • Nausea and Vomitting • very common • detrimental effect of vomitting on ICP • routine pharmacologic prophylaxis is reasonable

  19. Pain • m/c complaint : headache • treat with narcotics or NSAID • should be used pt with care a history of OSA • Disorders of Water Balance • most frequently encountered acute periop. Cx • DI(0.5%~25%) vs SIADH(9%~25%)

  20. DI • common but most often transient • typically manifests in the first 24-48h after surgery • treat with desmopressin : 0.1mg by orally or 1ug by subcut. • important to distinguish DI from others

  21. Syndrome of Inappropriate ADH Secretion • hyponatremia : common and manifest in a delayed manner • diagnosed by biochemical : low serum sodium, hypoosmolar serum, hyperosmolar urine, euvolemic state • fluid restriction : important therapy • hypertonic saline and IV urea • rapid correction : can cause central pontine myelinolysis

  22. Hypopituitarism • should be screened for signs of hypopituitarism • corticosteroid supplement after discharge • rapid wean and assay morning cortisol on a daily basis

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