Anesthesia Considerations 

Pituitary Surgery

 

 

Considerations

 

• Mass effects:

  • Neurologic impairment (bitemporal hemianopsia, cranial nerve palsies)

  • Potential ↑ ICP (rare, secondary to obstructive hydrocephalus)

• Neurohormonal effects/endocrinopathies:

  • Non-functional adenomas

  • Hypersecretory tumors (60%):  

    • Prolactin > GH > ACTH, TSH rare

    • Cushing’s, acromegaly

  • Endocrine deficiencies secondary to mass: 

    • Hormone production impaired in the following order

      • GH, LH, FSH, TSH, ACTH, prolactin ("Go Look For The Adenoma Please")

    • Panhypopituitarism

• Surgical Issues/complications:

  • Shared airway

  • Head up positioning:

    • Poor patient & airway access 

    • Bleeding into pharynx (coroner's clot) 

    • Venous air embolism

  • Systemic absorption of cocaine from mucosa → HTN, arrhythmias

  • Neurologic injury

  • Massive, difficult to access hemorrhage (cavernous sinus or carotid) 

  • Post-operative endocrine dysfunction

  • CSF leak/meningitis risk 

  • Diabetes insipidus

• Rapid smooth emergence 

 

 

Goals

 

• Optimize perioperative endocrine function (stress dose steroids), consult endocrinology

• Avoid further ↑ in ICP (if hydrocephalus)

• Provide a still field for microscopic surgery

• Minimize long acting sedatives (crisp emergence for neurological evaluation)

• Controlled emergence (minimize bucking/coughing/vomiting to ↓ risk of bleeding and CSF leak)

• Monitor for postoperative complications:

  • Diabetes insipidus (~40%)

  • SIADH (usually delayed)

  • Adrenal insufficiency & CV collapse (steroid coverage) 

  • Bleeding → ↑ ICP, brainstem compression, cranial nerve dysfunction 

  • CSF leak (risk of meningitis) 

  • Hypothalamic injury 

  • Cerebal ischemia

  • Stroke