๐จ Pituitary tumours can be hypo or hyper secretory : so they may exhibit Cushingoid status or cortisol deficiency. Accordingly the anesthetist has to look for diseases which are associated with these conditions
๐จ During the Pre Anesthetic Check up (PAC), we should screen for the presence of factors affecting airway management, like
✔️ Macroglossia
✔️ Soft tissue hypertrophy
✔️Obstructive Sleep Apnea (OSA)
And also for other associations like
✔️ DM
✔️ Systemic Hypertension
✔️ Ischemic Heart Disease
✔️ Heart failure
✔️ Pulmonary Hypertension
๐จ If there is cortisol deficiency ( can be diagnosed by short synacthen test) glucocorticoid supplementation should be continued peri-operatively.
๐จ The trans nasal trans sphenoidal approach offers better visibility and lesser incidence of postoperative Diabetes Insipidus (DI). NB: Both DI and SIADH can occur as postoperative complications; but incidence of DI is much higher (upto 50%) compared to that of SIADH.
๐จTrans nasal surgery requires oro-tracheal intubation, insertion of a throat pack to prevent blood going to trachea and stomach and infiltration of the nasal mucosa with local anesthetic and vasopressor ( by surgeon )
๐จ Establishment of an arterial line will help to intervene promptly during hemodynamic fluctuations that happens with infiltration or intense surgical stimulation
๐จ Surgeon may request various 'helps' from the anesthesiologist to make the suprasellar part of the tumor prolapse down into the sella, like:
✔️ Insertion of a lumbar drain and letting out of CSF
✔️ Maintenance of hypercapnea (upto 60 mm of Hg)
✔️ Fluid administration
๐จ As the patient is positioned with upper part of trunk and head elevated, there is chance for venous air embolism
๐จ Use of short acting drugs facilitate a rapid and smooth emergence which will help in neurological assessment
๐จ Presence of blood in pharynx, nasal packs and preexisting OSA, pose additional problems in managing the airway
๐จ We can't apply a nasal CPAP mask in such cases as it can cause pneumocephalus, meningitis and air embolism
Reference: Lim M, Williams D, Maartens N. Anaesthesia for pituitary surgery. J Clin Neurosci. 2006; 13(4): 413–418.
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