Transphenoidal surgery without steroid replacement in patients with morning serum cortisol below 9 μg/dl (250 Nmol/l).

Abstract

BACKGROUND:

Adrenal insufficiency is a feared complication in patients undergoing transphenoidal surgery (TSS). Using the insulin tolerance test (ITT) for the preoperative assessment of hypothalamic-pituitary-adrenal (HPA) status is less than ideal, and the morning serum cortisol (MSC) is often used as a proxy for ITT. However, neither the ITT nor the MSC level has been validated to indicate HPA sufficiency compared to a physiological gold standard such as patients' ability to withstand transphenoidal surgery.

OBJECTIVE:

To evaluate the intraoperative and postoperative course of nine patients with non-ACTH-secreting pituitary adenomas who did not receive intraoperative cortisol replacement despite having a preoperative MSC below 9 μg/dl (250 nmol/l) and to compare this with a set of patients with a preoperative MSC greater than 14.5 μg/dl (400 nmol/l) and another set of patients with MSC below 9 μg/dl (250 nmol/l) who received intraoperative cortisol administration.

METHODS:

Preoperative and day 1 and day 2 postoperative MSC, intraoperative anesthetic record, vital signs, fluid balance, medications, and complications were recorded.

RESULTS:

None of the patients experienced the full syndrome of adrenal insufficiency. One patient with a preoperative MSC <9 μg/dl (250 mol/l) had isolated postoperative fatigue and required cortisol replacement. No patient suffered any life-threatening complications. There were no differences among the three groups in their intraoperative or postoperative courses when compared for intraoperative hypotension, acute blood pressure drop, and administration of vasopressors.

CONCLUSION:

This study suggests that TSS can be performed safely in patients with preoperative MSC less than 9 μg/dl (250 nmol/l) in closely monitored settings without intraoperative cortisol administration. Further studies are warranted.

• Authors: Claudio De Tommasi, Jeannette Goguen, Michael D Cusimano
• Journal: Acta neurochirurgica (Acta Neurochir (Wien)) Vol. 154 Issue 10 Pg. 1903-15 (Oct 2012) ISSN: 0942-0940 [Electronic] Austria
• PMID: 22922981 (Publication Type: Journal Article)

Chemical References

• Steroids
• Adrenocorticotropic Hormone
• Hydrocortisone

Topics

• Adrenal Insufficiency (surgery)
• Adrenocorticotropic Hormone (blood)
• Aged
• Female
• Humans
• Hydrocortisone (blood)
• Male
• Middle Aged
• Pituitary Gland (surgery)
• Pituitary Neoplasms (surgery)
• Pituitary-Adrenal System (surgery)
• Postoperative Period
• Steroids (therapeutic use)
• Treatment Outcome