Postoperative assessment of the patient after transsphenoidal pituitary surgery

Abstract

While most transsphenoidal pituitary surgery is accomplished without complication, monitoring is required postoperatively for a set of disorders that are specific to this surgery. Postoperative assessments are tailored to the early and later postoperative periods. In the early period, which spans the first few weeks after surgery, both monitoring of anterior and posterior pituitary function and managing neurosurgical issues are the focus of care. Potential disruption of pituitary-adrenal function is covered with perioperative glucocorticoids. Various strategies exist for ensuring the integrity of this axis, but typically this is done by measuring a morning cortisol on the 2nd or 3rd postoperative days. Patients with levels <10 microg/l should continue therapy with reassessment in the later postoperative period. Monitoring for water imbalances, which are due to deficiency or excess of ADH (DI or SIADH, respectively), is accomplished by continuous accounting of fluid intake, urine output and specific gravities coupled with daily serum electrolyte measurements. DI is characterized by excess volumes of inappropriately dilute urine, which can lead to hypernatremia. Most patients maintain adequate fluid intake and euvolemia, but desmopressin therapy is required for some. SIADH, which peaks in incidence on 7th postoperative day, presents with hyponatremia that can be severe and symptomatic. Management consists of fluid restriction. Neurosurgical monitoring is primarily for disturbances in vision or neurological function, and although uncommon, for CSF leak and infections such as meningitis. In the later postoperative period, the adrenal, thyroid and gonadal axes are assessed. New persistent hypopituitarism is rare when transsphenoidal surgery is performed by an experienced surgeon. Various strategies are available for assessing each axis and for providing replacement therapy in patients with deficiencies. Long term monitoring with assessments of visual, neurological and pituitary function coupled with pituitary imaging is necessary for all patients who have undergone surgery, irrespective of the hormone status of their tumors.

Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic–pituitary–adrenal axis before and after pituitary surgery?

“…Therefore, it should be kept in mind that the cortisol level measured on the 2nd or 3rd postoperative day might not reflect, and may be higher than that at 1 week. Patients with cortisol levels lower than 220-270 nmol/l (8-10 mg/dl) on the 2nd or 3rd postoperative day are discharged and recommended for low-dose glucocorticoid replacement therapy (26)(27)(28)(29). The results of this study are consistent with these practices.…”

Day 5 Morning Serum Cortisol Predicts Hypothalamic-Pituitary-Adrenal Function after Transsphenoidal Surgery for Pituitary Tumors

“…However, adrenal insufficiency secondary to the disruption of pituitary function is a wellrecognized complication of TSS. Therefore postoperative biochemical evaluation of the integrity of the hypothalamic-pituitary-adrenal (HPA) axis is imperative (2 ).…”

“…The use of ITT is also contraindicated in elderly patients and patients with cardiovascular disease or epilepsy (4 ). In light of its associated risks, performing ITT is not appropriate during the first few postoperative days, and most centers delay the ITT until 4 -6 weeks after TSS (2,6 ).…”

Nursing Care of an Individual with Pituitary Tumor

“…Available phone numbers are provided for use in emergency situations. Patient appointments for outpatient visits are arranged [6,13,22,23,26].…”

“…All medicines (hypoglycemic agents, diuretics, synthetic hormone replacement, etc.) that increase the risk of hyponatremia are checked, if necessary, intravenous sodium chloride solutions are administered according to the physician's order [6,13,[26][27][28].…”