WJOES

10.5005/jp-journals-10002-1114
Pituitary Surgery and Anesthetic Management: An Update
ORIGINAL ARTICLE

Pituitary Surgery and Anesthetic Management: An Update

Surender K Malhotra, Kiran Sharma, Vikas Saini

ABSTRACT thyroid-stimulating hormone (FSH), luteinizing hormone

Out of all the brain tumors, 10% are pituitary tumors. Surgical (LH), prolactin, thyroid stimulating hormone (TSH) and
interventions in this field have advanced and so have techniques endorphins. Posterior pituitary (neurohypophysis) secretes
of anesthesia and intensive care. Presenting features of the antidiuretic hormone (ADH) and oxytocin.
patients with pituitary tumors are often due to excessive or
Clinical presentations of pituitary gland may be of three
decreased secretion of hormones. Most commonly performed
procedure is transsphenoidal pituitary surgery which requires types: Firstly, due to increased secretions of hormones;
skillful anesthetic technique as a number of associated secondly, due to decreased secretions of hormones and,
comorbidities may exist. For a positive surgical result, a team thirdly, due to mass effects.
consisting of endocrine surgeon, endocrinologist, neurosurgeon
and anesthesiologist is a must. An emphasis is required on
preoperative evaluation of airway, endocrinal and neurological
PREOPERATIVE CONSIDERATIONS
status. The understanding of pathophysiology, perioperative To assess the degree of pituitary functions, an adequate
anesthetic management, awareness of likely complications and
postoperative care, results in successful outcome. preoperative assessment and endocrinology consultation
should be taken. Hormonal and antihypertensive
Keywords: Pituitary tumors, Anesthesia, Neurosurgery.
medications should be administered till the day of surgery.
How to cite this article: Malhotra SK, Sharma K, Saini V. To exclude lesions, like hydrocephalus, computed
Pituitary Surgery and Anesthetic Management: An Update.
tomography (CT) or preferably magnetic resonance imaging
World J Endoc Surg 2013;5(1):1-5.
(MRI) should be performed. Documentation of visual fields
Source of support: Nil is mandatory. Nasal obstruction after the procedure due to
Conflict of interest: None packs must be explained to the patient.3

INTRODUCTION CARDIOVASCULAR EVALUATION

Anesthetic considerations, for a patient undergoing pituitary Problems, such as coronary artery disease, arrhythmias, left
surgery, are always a challenge to the anesthesiologist. The ventricular hypertrophy, valvular heart diseases, congestive
management requires the knowledge of neurosurgical heart failure and cardiomyopathies are quite common in
aspects of anesthesia in general and pituitary disease in pituitary disorders.4-6 In cases of obstructive sleep apnea,
particular. The pathophysiology involving the hormonal pulmonary hypertension may occur resulting in respiratory
alterations due to pituitary disease may have significant problems after the surgery. Hypertension occurs in
effect on the outcome of the surgery. The perioperative Cushing’s disease and acromegaly.4,5 Cardiac diseases cause
anesthetic considerations also depend on the technique of mortality in acromegaly patients especially due to
surgery.1 hypertension and left ventricular hypertrophy.7,8 ST and
Pituitary gland weighs 0.5 to 0.9 gm and 15 × 10 mm in T wave changes and conduction block are frequently
size.2 The gland lies in sella turcica at the base of skull. observed during stress.9,10
Superior relations of the gland are hypothalamus and third
ventricle. Anterior and posterior relations are sphenoid AIRWAY DIFFICULTY
sinuses and sphenoid clivus respectively. Laterally, it is Hypertrophy of the soft tissues of the nose, tongue,
related to cavernous sinus, internal carotid arteries and turbinates and epiglottis is observed following increased
cranial nerves III to VI. Pituitary gland has two lobes, release of GH. Change in voice may caution the stenosis of
anterior and posterior. The anterior lobe (adenohypophysis) larynx.1 Facial features may be course and bony prominence
forms two-third of the gland. Pituitary gland lies outside may lead to prognathism.11 Thyroid goiter may be present
the blood-brain barrier. Blood supply to the gland is from in acromegaly patients causing compression of trachea.1,12
branches of internal carotid; inferior and superior A thorough assessment of airway is mandatory in
hypophyseal arteries. Venous drainage from pituitary gland acromegaly patients.13 A preoperative flow volume studies
goes to cavernous sinuses and internal jugular vein. and indirect laryngoscopy is recommended.14,15 A history
Hormones secreted by anterior pituitary are growth of snoring and daytime sleep may guide the anesthesiologist
hormone (GH), adrenocorticotropic hormone (ACTH), to manage perioperative airway.12,13
World Journal of Endocrine Surgery, January-April 2013;5(1):1-5 1
Surender K Malhotra et al

PROLACTINOMAS consciousness, vision loss or headache and may require

emergency surgical intervention. These patients are prone
These are most common kind of secretory pituitary tumors.
to water intoxication and low blood sugar levels and may
Frequently, these are microadenomas usually seen in female
prove sensitive to anesthetic drugs leading to prolonged
population. Big size macroadenomas (>1 cm) affect males
recovery.21 The patients who have reduced ACTH level must
and may lead to visual problems due to compression of optic
be given glucocorticoid cover to avoid hypoadrenal crisis.1
nerve. MRI and estimation of prolactin (>400 mU/l) are
It is mandatory to replace thyroxin (50-150 μg/day).
diagnostic. Bromocriptine administration is the drug of
Intraoperative hypotension should be countered with
choice in treating these tumors but it may cause perioperative
vasopressors.
hypotension and nausea. If there is no response to medical
In addition, there may be ‘mass effect’, i.e. if macro-
therapy and cerebrospinal fluid (CSF) leak occurs, surgery
adenomas is >1 cm it may compress optic nerve leading to
is indicated.16
vision impairment. Large lesions may even increase the
ACROMEGALY (EXCESS OF GH) intracranial pressure (ICP) resulting in hydrocephalus.
Acromegaly is a chronic disease involving various systems PITUITARY SURGERY: TECHNIQUES
and is due to excessive release of GH from macroadenoma.
Pituitary surgery is indicated, when medical therapy fails
It occurs mostly during fourth or fifth decade of life.
or as primary therapy for some pituitary lesions. Currently,
Anesthesiologist may find difficulty in mask ventilation,
most of the procedures are carried out by transsphenoidal
laryngoscopy and intubation due to large tongue and
technique. Transcranial approach is used for large tumors
receding chin. However, cricoid pressure and tube or when transsphenoidal technique is not successful. There
exchanger may be useful in difficult intubation.17 Awake is minimal bleeding as well as direct access is possible by
intubation, using fiberoptic bronchoscope, is the method of trans-sphenoidal technique. However, risks of this approach
choice. Majority of these patients have history of obstructive are CSF rhinorrhea, vascular trauma, meningitis, cranial
sleep apnea (OSA) and may pose respiratory and nerve damage and vasospasm, leading to cerebral
cardiovascular problems in postoperative period.18 Muscle ischemia.22
disorders and scoliosis may further worsen the situation. In Local application of local anesthetics and vaso-
addition, these patients may have cardiac problems, such constrictor helps reducing the bleeding in surgical field.
as hypertension, left ventricular hypertrophy, arrhythmias, Topical phenylephrine may be preferred as adrenaline may
coronary artery disease and cardiomyopathy. Echocardio- lead to hypertension in Cushing’s disease. Cocaine is not
graphy may indicate the pulmonary pressures and left popular as it causes arrhythmias and coronary spasm. Safe
ventricular functions. Peripheral venous access and arterial vasoconstrictor is xylometazoline for topical use. 23
cannulation may be challenging. Increase in blood sugar Lignocaine (1%) with adrenaline 1:200,000 is recommended
level is a common finding. Respiratory care and monitoring for effective analgesia and vasoconstriction.24 In case of
after the surgery are undertaken in critical care unit. hypertension, beta-blockers and nitroglycerine may be
required.25
CUSHING’S DISEASE (EXCESS OF ACTH)
Problems of Cushing’s disease are features of cardiovascular STEROID SUPPLEMENTATION
disease, diabetes mellitus and immunosuppression. Delicate Glucocorticoids cover in patients with hypopituitarism is
skin and osteoporosis may cause difficulty in venous access commenced an evening before the surgery (100 mg of
and incidence of spontaneous fractures respectively.19,20 hydrocortisone intravenously), repeated before start of
Majority of patients have hypertension, coronary artery surgery as well as in the evening. 26 Perioperative
disease and left ventricular hypertrophy leading to morbidity glucocorticoid cover in all patients with Cushing’s disease
during and after surgery.1 Intraoperative bleeding is a is mandatory. To confirm ACTH deficiency, cortisol test is
frequent problem. Obesity may complicate the airway recommended before administration of steroid cover is
management.20 These patients are prone to aspiration as decided. In case of abnormal results, usual maintenance
gastric reflux is frequent.12 Postoperative ventilation may doses of glucocorticoid should be started (Table 1). If no
be required owing to pre-existing myopathy.20 ACTH deficiency is detected, no glucocorticoid supple-
mentation is required.
HYPOPITUITARISM
In case, pituitary tropic hormones are normal and peripheral LUMBAR CSF DRAIN
hormones are decreased, hypopituitarism is the likely Indication of lumbar CSF drain is massive suprasellar
diagnosis. 19 Features of this situation are loss of extension of tumor. The level of insertion of this drain should
2
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Pituitary Surgery and Anesthetic Management: An Update

Table 1: Supplementation of glucocorticoids

Plasma cortisol levels (nmol/l) Hydrocortisone dose (mg) Tests required
<100 15-30 mg/d Nil
100-250 10-20 mg/d HPA tests required
250-450 Only during stress HPA tests recommended
>450 No supplementation No further tests needed
HPA: Hypothalamic pituitary axis

be L3-4 interspace. The catheter is introduced in a cephalad A reinforced orotracheal tube is recommended,
direction.13 Five to 10 ml of air or normal saline is introduced positioned in the left corner of the mouth.
into the subarachnoid space, which by pressure effect pushes A throat pack is inserted and ensured that it is removed
the suprasellar extension of the tumor into the surgical field, before extubation.
leading to complete excision of the tumor.1 This procedure While deciding the technique of anesthesia, the basic
must be performed under absolute sterile setting. A Valsalva principles of neuroanesthesia should be followed.
or Queckenstedt’s maneuver is a satisfactory alternative in Choice of anesthetics is made on the presence of
case there is no lumbar drain.27 coexisting diseases and past history of anesthesia exposure.
One of the two techniques, i.e. total intravenous anesthesia
CONTROLLED HYPERCAPNIA (TIVA) or balanced anesthesia using muscle relaxants with
A permissive hypercapnia with PaCO2 of 60 mm Hg is inhalational agents may be selected.31 Only short-acting
recommended as successful way to increase the ICP to shift agents should be used to facilitate rapid recovery, because
the suprasellar part of a tumor into the sella for easy surgical postoperative airway maintenance is a problem. It is prudent
excision.28 A high normocapnia (40-45 mm Hg) is also to avoid nitrous oxide in case there is increased ICP.26
recommended for the purpose.22 However, hypercarbia may Majority of the inhalational agents, such as isoflurane,
result in hypertension, tachycardia and a reduced myocardial sevoflurane and desflurane increase the cerebral blood flow.
perfusion. This results in rise in ICP but it depends on duration of
their use. Producing hypocarbia by hyperventilation reduces
GOALS OF ANESTHESIA the chances of rise in ICP. Isoflurane causes minimum
The aim of anesthetic technique must be targeted toward increase in ICP out of all volatile agents.32
hemodynamic stability, maintaining adequate cerebral In case of raised ICP, TIVA is the better choice.26 For
oxygenation and a normal ICP.29 There should be an ideal rapid recovery, induction agents like propofol and
surgical exposure and smooth recovery at the end of surgery. analgesics, such as remifentanil are preferred. To ensure
Aim should be the prevention and management of quick emergence, inhalational agents like sevoflurane or
intraoperative complications. Intra-arterial measurement of desflurane should be used since their blood solubility is
blood pressure is mandatory in all the patients. Depending low. Neuromuscular blocking agents are must for complete
on the coexisting conditions of the patient, central venous relaxation and effective ventilation.
pressure monitoring may be considered. If the surgery is done in sitting position, chances of air
embolism increase in case some cavernous sinus ruptures.
AIRWAY MANAGEMENT During transsphenoidal surgery, a negligible blood loss
In patients, such as acromegaly and Cushing’s, mask occurs unless injury to a big vessel, such as carotid artery
ventilation may not be easy. occurs. Valsalva maneuver may be used to test for any CSF
Fiberoptic intubation, that may be awake and oral, is leak after excision of tumor. Before its reconstruction, sella
the recommended technique in case there is recognized is packed with autologous fat to prevent any CSF leak. The
difficult airway. In acromegaly, the difficult tracheal administration of perioperative paracetamol is also
intubation may not be predicted. recommended due to its highly favorable risk: benefit ratio.33
Southwick and Katz30 defined four grades of airway NSAIDs have been linked to postoperative hematoma
involvement in acromegalic patients. Obesity in patients formation34 but it is controversial. Tramadol is less effective
with Cushing’s syndrome may contribute in making the and causes more sedation and postoperative nausea and
airway difficult, particularly the mask ventilation. vomiting.35

ANESTHETIC TECHNIQUE MONITORING

All the patients should have large-bore intravenous access Routine monitoring, such as ECG, pulse oximetry, EtCO2
for rapid volume resuscitation. and invasive arterial blood pressure are carried out. Majority
World Journal of Endocrine Surgery, January-April 2013;5(1):1-5 3
Surender K Malhotra et al

of the patients with Cushing’s disease and acromegaly may worsening discussed with the surgeon for any further
have features of cardiovascular disease that increase the action.38 Neuroendocrine abnormalities after pituitary
anesthesia-related morbidity, particularly if intraoperative surgery are common. Diabetes insipidus (DI) occurs within
hemodynamic instability occurs. These patients require the first 24 hours and disappears in a week. Desmopressin
invasive arterial blood pressure monitoring in case of (nasally or parenteral) is given, if DI persists but beware of
fluctuations in BP occurs. 36 Visual evoked potential hyponatremia. Hormonal replacement therapy is required
monitoring is employed, if tumor is affecting the visual field. in all patients after surgery. Steroid replacement therapy is
Since, this monitor has sensitivity to anesthetics, results are undertaken in a reducing regime. Endocrinologists should
not reliable.26 be consulted for all replacement therapy, i.e. steroids or
hormones.39
POSITIONING DURING SURGERY
For transsphenoidal surgery, a head up position (operative PITUITARY APOPLEXY
field above the level of the heart) is required as it minimizes The term is defined as acute hemorrhagic infarction of a
bleeding during the surgical procedure, though the chances gland whose blood supply is earlier compromised by a tumor
of venous embolism increase in this position.37 The neck of or pregnancy.40 It may be due to obstetric hemorrhage, sickle
the patient is tilted laterally to the left, extended and secured cell crisis and head injury. Usually, there is acute failure of
in a Mayfield clamp. This immobilizes the head and anterior lobe function. The posterior lobe function generally
facilitates application of the stereotactic frame, allowing remains normal. Common features are severe headache,
the surgeon a midline approach. The elderly patients have nausea and vomiting, visual field defects and cranial nerve
more rigid necks, so the table can be tilted laterally to obtain palsies. It is managed by treating adrenocortical failure with
the face-on position for easy access to the field. intravenous fluids, urgent transsphenoidal decompression
and replacement of hydrocortisone.
INTRAOPERATIVE COMPLICATIONS
Despite the semi-sitting position, air embolism is infrequent. CONCLUSION
Bleeding from carotid artery damage is not common but is Pituitary surgery involves a multidisciplinary approach
a serious complication if it takes place. Other structures consisting of endocrinologist, the neurosurgeon, radiologist
likely to be damaged are cranial nerves II to VI, optic nerves/ and the anesthesiologist. Their teamwork and coordination
chiasm and venous sinuses. Transcranial approach may is of immense importance. Preoperative optimization of
result in all the complications like any other craniotomies. systemic diseases due to pituitary involvement must be
Anticonvulsant prophylaxis is a must. Lesion of olfactory carried out. Appropriate anesthetic management based on
nerve may lead to anosmia. patient’s disease and surgical procedure should be carried
out intraoperatively. Fast recovery from anesthesia is vital
EMERGENCE
because early neurologic assessment can disclose most
Pharyngeal packs are removed at the end of the procedure serious surgical complications. Follow-up of all the patients
and suctioning of mouth cavity is carried out. Once the with endocrinologist to assess their hormonal status is
patient starts breathing spontaneously and the reflexes mandatory.
return, extubation is undertaken. If patient is awake after
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