1 / 27

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

vesna
Download Presentation

Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related