Anesthetic management during transsphenoidal pituitary surgery

Abstract

Purpose of reviewPituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. Recent findingsAn endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SummaryTranssphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.

Comparison of the effects of inhalational and total intravenous anesthesia on quality of recovery in patients undergoing endoscopic transsphenoidal pituitary surgery: a randomized controlled trial

“…However, it seems that the benefits of each anesthetic method could not lead to an improvement in the quality of recovery as well as a decrease in the length of hospital stay. A recent review article on perioperative anesthetic management during transsphenoidal pituitary surgery did not recommend a particular anesthetic technique over another [8]. Therefore, the selection of the most appropriate anesthetic method should be case-specific, according to the condition and surgical situation of the individual patient.…”

“…Furthermore, rapid and smooth emergence is desirable in patients undergoing this type of surgery because the immediate postoperative use of nasal packing Ivyspring International Publisher requires conscious mouth breathing and may cause difficulties in airway management. Adequate emergence also lowers the risk of surgical complications such as cerebrospinal fluid rhinorrhea due to coughing and enables a prompt neurological examination [7][8][9][10]. Moreover, there is an increasing demand for enhanced postoperative recovery after endoscopic pituitary surgery that is not limited to the immediate postoperative period [11].…”

Ultrasound assessment of gastric contents and volume in patients before and after endoscopic endonasal transsphenoidal surgery: a prospective observational study

“…First, during this special neurosurgical procedure, the head of the bed was elevated 15-20° to reduce bleeding and cerebrospinal uid leakage. However, this position potentially allows the downward ow of blood, cerebrospinal uid, and irrigation uid (used to clean the endoscope lens and operating eld) from the oropharynx to the oesophagus and stomach due to gravity [17,19]. Second, the upper and lower oesophageal sphincter tone, barrier pressure between the oesophagus and stomach, and intragastric pressure were signi cantly lower in patients receiving general anesthesia [1,[20][21][22].…”

“…The use of throat packing may effectively prevent the downward ow of irrigation uid and blood from the oropharynx to the oesophagus and stomach. Moreover, perfect hemostasis, intraoperative suctioning, prophylactic antiemetic drugs, maintaining hemodynamic stability, smooth emergence from anaesthesia, and orogastric suctioning to remove ingested blood from the stomach could be useful in reducing the rate of postoperative nausea and vomiting [1,18,19,25]. In addition, delayed extubation is mandatory in patients with a compromised level of consciousness.…”

Ultrasound assessment of gastric contents and volume in patients undergoing endoscopic endonasal transsphenoidal surgery: a prospective observational study

“…Patients undergoing EETS have a significant incidence of postoperative nausea and vomiting (PONV) due to leakage of cerebrospinal fluid and fat grafting 9 . In addition, during this special surgical procedure, ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to a significant increase in gastric volume 10 . Ingested blood is generally considered a potent emetic that can also lead to frequent postoperative vomiting 10 , 11 .…”