Post-operative Orders for Transphenoidal Surgery

Complications after TSP surgery:

  • post-operative hematomas
  • epistaxis
  • ischemic events
  • hydrocephalus
  • CSF leaks
  • meningitis
  • diabetes insipidus

 

Nasal packing

  • for intraoperative leaks requiring sellar floor reconstruction, Cushing’s Disease and acromegaly
  • typically removed POD#1

 

Post-op Epistaxis

  • common occurrence, routine nasal packing x 2-3days
  • if refractory, reoperation or endovascular embolization of arterial bleeder

 

Electrolyte disturbances / DI / hyponatremia

  • strict measurement of Is and Os, daily weight
  • frequent sodium levels
  • UO >250 cc/hr x 2-3 hours – check serum Na and USG
  • DI is usually transient phenomenon
  • DDAVP at bedtime (even if patient can drink to satiety) in clear-cut DI to allow patients to sleep comfortably
  • SIADH and delayed hyponatremia 1 week after – check serum labs on POD#7
    • mild hyponatremia, asymptomatic – manage at home with fluid restriction and f/u labs
    • moderate to severe hyponatremia or symptomatic – admit for fluid restriction, Na checks and hypertonic saline

 

Hypopituitarism

  • preoperative evidence of hypopituitarism
    • stress dose steroids perioperatively ad keep on physiological maintenance doses until appropriate to assess pituitary function in controlled manner
  • evidence of hormonal excess
    • lab testing during first few days after surgery to assess for endocrinological remission
    • if Cushing’s – no steroids during operation unless necessary, check serum cortisol level post-op q6h until nadir, if <5ug/dL, esp if symptomatic hypocortisolemia, immediate glucocorticorticoid therapy IV then transition to physiologic oral maintenance doses until function can be reassessed in delayed and controlled setting
  • normal cortisol function prior to surgery
    • no intraoperative  glucocorticoids
    • assess post-op with AM fasting cortisol on POD#1 and POD#2
    • if new hypocortisolemia (cortisol <10 ug/dL) – start glucocorticoid replacement until reassessed by endocrinologist in delayed fashion
  • Acromegaly
    • POD#1 serum GH level may predict early remission
    • gold standard test is delayed IGF-1 level 6 weeks after surgery
    • successful tumor resection – brisk fluid diuresis of third-spaced fluid, mimics DI – check serum Na and USG
  • Prolactinomas
    • POD1 or POD#2 am prolactin, typically normalizes in cases of remission
  • Check cortisol POD#7 to rule out delayed hypocortisolemia

 

Discharge

  • routine follow-up 1 week after surgery then 6 weeks post-op (for routine endocrine and post-op evaluation) [equilibration of PA axis and longer half-life of thyroid hormone]
  • MRI 3 months after OR to allow resolution of post-op changes and assess extent of tumor resection
  • routine imaging annually or more often as indicated (WOF delayed tumor recurrence up to several years) – continued endocrinological and imagnig surveillance even beyond a decade

 

REFERENCE:

Zada, G. et al.  Asian J Neurosurg. 2010 Jan-Jun; 5(1): 1–6. PMCID: PMC3198670 Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery

 

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