An Effective and Practical Fluid Restriction Protocol to Decrease the Risk of Hyponatremia and Readmissions After Transsphenoidal Surgery

Abstract

BACKGROUND Delayed hyponatremia is a common complication following transsphenoidal surgery (TSS) of pituitary lesions, which leads to significant patient morbidity, as well as increased hospital costs associated with readmission. OBJECTIVE To report the effects of fluid restriction, during a postoperative period of 4 d, to decrease rates and readmissions for hyponatremia in a cohort of patients undergoing TSS. METHODS Because of our observed postoperative rates of hyponatremia, we implemented 1000-mL fluid restriction limited to postoperative days (POD) 4 to 8 in consecutive patients undergoing surgery at our center between March 2018 and January 2019. Patients were monitored for the development of hyponatremia and readmissions. We compared outcomes with those of patients who had undergone TSS prior to fluid restriction. RESULTS Data from 57 patients who underwent TSS following implementation of fluid restriction were compared to prior patients who underwent TSS without restriction. The rate of hyponatremia in patients (n = 57) prior to fluid restriction was 12.3%. Following implementation of fluid restriction, we had zero cases of hyponatremia or readmissions. We found body mass index to be inversely related to the risk of hyponatremia and readmissions. Furthermore, male gender, follicle stimulating hormone and/or luteinizing hormone staining on pathology, and administration of preoperative and intraoperative glucocorticoids were associated with decreased risk of hyponatremia readmissions. CONCLUSION The implementation of 1000-mL fluid restriction between POD 4 and 8 is a highly successful and simple approach to decrease the risk of delayed hyponatremia after TSS.

The management and outcome of hyponatraemia following transsphenoidal surgery: a retrospective observational study

“…This series showed that one-third of patients did not respond to fluid restriction within the first 3 days of treatment, while responders required a median time period of 4 days to restore normal sodium. These management outcomes are in contrast to other studies by Burke et al and Winogard et al[ 5 , 42 ] , who advocate the implementation of 1000-mL fluid restriction following discharge for all patients during the first week following transsphenoidal surgery, irrespective of whether they have hyponatraemia. They reported successful outcomes of higher sodium levels and less hospital readmission in the interventional group than those who had no restriction.…”

“…A potential strategy to decrease readmissions due to hyponatraemia would include routine assessment of serum sodium levels in all patients 5–7 days after operation, allowing early identification of hyponatraemia and prompt initiation of fluid restriction on outpatient basis[ 24 ]. An alternative pathway to lower readmission rate is to limit fluid intake in all patients post discharge [ 8 , 42 ]. However, to date there is no general consensus in respect to the best strategy to identify patients at risk and manage delayed hyponatraemia post discharge.…”

In-Hospital Endocrinology Consultation After Transsphenoidal Surgery: Is It Always Necessary?

“…Delayed post-operative hyponatremia due to SIADH has been reported as being common after TSS, reported in a wide range from 2.3 to 53% of patients. [22][23][24][25] The overall risk of delayed SIADH after discharge in our cohort was similar in the IHEC (4.2%) and no-IHEC (5.4%) groups. It is important to note that the IHEC Physician's Guide was not designed for, and does not reliably predict, the development of delayed SIADH; therefore, all patients should be routinely assessed for hyponatremia after discharge.…”

Multidisciplinary management of acromegaly: A consensus

“…Diabetes insipidus occurs at a rate similar to surgically treated pituitary tumors (10-15%), and is usually transient. The syndrome of inappropriate antidiuretic hormone secretion may occur 5-14 days after surgery and requires vigilance, with frequent monitoring of serum sodium levels and possibly fluid restriction (LQ) (58,59).…”