Transphenoidal resection of pituitary tumor - Revision history

Jchen900 at 00:53, 8 September 2023

2023-09-08T00:53:21Z

@@ Line 157: / Line 157: @@
 *Smooth awake extubation (i.e., remifentanil wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.
 *Avoid positive pressure masking after extubation.
 ==Postoperative management ==

Ddiaczok: Additional Info regarding GH tumors: preop eval, airway.

2022-09-22T17:36:07Z

Additional Info regarding GH tumors: preop eval, airway.

← Older revision		Revision as of 10:36, 22 September 2022
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	\|		\|
	*ACTH or GH secreting tumors may lead to airway abnormalities		*ACTH or GH secreting tumors may lead to airway abnormalities
			*GH: macroglossia, enlarged epiglottis, RLN palsy, subglottic stenosis, enlarged nasal turbinates
	\|-		\|-
	\|Neurologic		\|Neurologic
	\|		\|
	*Baseline neuro exam		*Baseline neuro exam
			*GH prone to peripheral neuropathies.
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|
	*Hyperthyroid patients may have ECG abnormalities		*Hyperthyroid patients may have ECG abnormalities
			*GH pts may have HTN, LVH, diastolic dysfunction, arrhythmias, CAD
	\|-		\|-
	\|Renal		\|Renal
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	*ETT with straight connector		*ETT with straight connector
	**Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.		**Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.
			**GH: glottic opening may be very distal, traditional ETT may not be long enough, consider MLT 6.0mm

	===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===		===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===

Chris.Rishel at 00:30, 20 September 2022

2022-09-20T00:30:02Z

← Older revision		Revision as of 17:30, 19 September 2022
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	** Only 0.1-0.2% malignant carcinomas		** Only 0.1-0.2% malignant carcinomas
	* Approximately 35% are invasive into adjacent bony and/or vascular structures		* Approximately 35% are invasive into adjacent bony and/or vascular structures
	* Approximately 75% of tumors are functional (hormone-secreting)<ref>{{Cite book\|last=Reddy\|first=SS\|url=https://www.worldcat.org/oclc/234428919\|title=The Cleveland Clinic Foundation intensive review of internal medicine\|last2=Hamrahian\|first2=AH\|date=2009\|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins\|others=James K. Stoller, Franklin A. Michota, Brian F. Mandell, Cleveland Clinic Foundation\|isbn=978-0-7817-9079-6\|edition=5\|location=Philadelphia\|chapter=Pituitary Disorders and Multiple Endocrine Neoplasia Syndromes\|oclc=234428919}}</ref>		* Approximately 75% of tumors are functional (hormone-secreting)<ref name=":0">{{Cite book\|last=Reddy\|first=SS\|url=https://www.worldcat.org/oclc/234428919\|title=The Cleveland Clinic Foundation intensive review of internal medicine\|last2=Hamrahian\|first2=AH\|date=2009\|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins\|others=James K. Stoller, Franklin A. Michota, Brian F. Mandell, Cleveland Clinic Foundation\|isbn=978-0-7817-9079-6\|edition=5\|location=Philadelphia\|chapter=Pituitary Disorders and Multiple Endocrine Neoplasia Syndromes\|oclc=234428919}}</ref>
	* Mass effect of tumor can lead to decreased secretion of one or more pituitary hormones and other neurologic deficiencies		* Mass effect of tumor can lead to decreased secretion of one or more pituitary hormones and other neurologic deficiencies

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	*Pituitary tumors can be classified as functional (hormone-secreting) or nonfunctional (not hormone-secreting)		*Pituitary tumors can be classified as functional (hormone-secreting) or nonfunctional (not hormone-secreting)
	**Prolactin > GH > ACTH > LH/FSH > TSH		**Prolactin > GH > ACTH > LH/FSH > TSH<ref name=":0" />
	*Endocrine deficiencies from mass effect		*Endocrine deficiencies from mass effect
	**GH > LH/FSH > TSH > ACTH > Prolactin		**GH > LH/FSH > TSH > ACTH > Prolactin

Chris.Rishel: Expanded on overview and preoperative management

2022-09-20T00:28:21Z

Expanded on overview and preoperative management

Show changes

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:40:02Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:40, 5 April 2022
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	\| airway = ETT		\| airway = ETT
	\| lines_access = PIV x 2		\| lines_access = PIV x 2
	~~Art~~ line		Arterial line
	\| monitors = Standard ASA		\| monitors = Standard ASA
	5-lead EKG		5-lead EKG
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	* PIV x 2 (20g for drips, 18g+ for bolus)		* PIV x 2 (20g for drips, 18g+ for bolus)
	* ~~Art~~ line		* Arterial line

	* If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.		* If patient is hemodynamically stable, consider placing art line after the 180 spin as surgical team can prep simultaneously. It also reduces the chance of inadvertent line dislodgment while spinning.

Chris.Rishel at 07:24, 5 April 2022

2022-04-05T07:24:05Z

← Older revision		Revision as of 00:24, 5 April 2022
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	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ETT		\| airway = ETT
	\| lines_access = PIV x 2~~<Br>~~Art line		\| lines_access = PIV x 2
	\| monitors = Standard ASA~~<Br>~~5-lead EKG~~<Br>~~Core temp~~<Br>~~UOP~~<Br>~~EEG ~~(optional)~~		Art line
	\| considerations_preoperative = Characterize baseline neurologic deficits (i.e., visual field defects)~~<Br>~~Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted		\| monitors = Standard ASA
	\| considerations_intraoperative = Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding~~<Br>~~Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation		5-lead EKG
	\| considerations_postoperative = PONV prophylaxis~~<Br>~~Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)		Core temp
			UOP
			± EEG
			\| considerations_preoperative = Characterize baseline neurologic deficits (i.e., visual field defects)
			Characterize type of adenoma (secreting vs non-secreting) and which type of hormone secreted
			\| considerations_intraoperative = Avoidance of hypertension as it can worsen visual of endoscopic surgical field due to bleeding
			Avoid turbulent emergence; avoid positive pressure mask ventilation on extubation
			\| considerations_postoperative = PONV prophylaxis
			Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)
	}}		}}

	~~Provide~~ a ~~brief summary of this surgical~~ procedure ~~and its indications here~~.		A '''transphenoidal resection of pituitary tumor''' is a neurosurgical procedure performed through an intranasal exposure to remove a tissue from the sella turica.

	== Preoperative management ==		== Preoperative management ==
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	* Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)		* Propofol gtt (if TIVA, start at 100-150 mcg/kg/min and consider EEG monitoring/Sedline/BISl; titrate to effect)
	* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)		* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
	* ~~+/-~~ Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)		* ± Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
	* No steroids unless specifically asked; may interfere with AM cortisol measurement the next day		* No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
	* Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.		* Pinning of the head using Mayfield pins by neurosurgery will cause a pain/sympathetic surge. Prepare to bolus 1-2 mcg/kg of remi 2-3 minutes prior to pinning; coordinate with surgeons.
	* ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension		* ENT will inject lidocaine with epinephrine, watch for inadvertent IV injection or mucosal absorption→ transient tachycardia, hypertension
	* Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection		* Combined ENT/Neurosurgery case - ENT for exposure, neurosurgery for tumor resection
	* As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested ~~remi~~ gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.		* As with many ENT cases in the nasopharynx, can be very stimulating, hence the suggested remifentanil gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
	* Consider short-to-intermediate acting BB (i.e, esmolol, ~~labelol~~) for HTN/stimulation not controlled by ~~remi~~ bolus/gtt. HTN will worsen bleeding during ENT portion.		* Consider short-to-intermediate acting BB (i.e, esmolol, labetalol) for HTN/stimulation not controlled by remifentanil bolus/gtt. HTN will worsen bleeding during ENT portion.
	* Surgeons will ask for ~~Valsava~~ during the case.		* Surgeons will ask for Valsalva during the case.
	* Note down when throat pack is placed in and taken out during case.		* Note down when throat pack is placed in and taken out during case.
	* Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection		* Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection
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	* Paralytic reversal (if used).		* Paralytic reversal (if used).
	* Spin back to neutral (particularly, if solo).		* Spin back to neutral (particularly, if solo).
	* Smooth awake extubation (i.e., ~~remi~~ wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.		* Smooth awake extubation (i.e., remifentanil wake-up: decrease gtt to 0.03-0.05 mcg/kg/min for extubation). Patients may not spontaneously breath initially even if all volatile/propofol if out of the system, but if gently encouraged, will open their eyes and follow commands.
	* Avoid positive pressure masking after extubation.		* Avoid positive pressure masking after extubation.

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:46:15Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:46, 21 February 2022
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	\|		\|
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|		\|
	\|-		\|-

Chris.Rishel at 21:05, 21 February 2022

2022-02-21T21:05:59Z

← Older revision		Revision as of 14:05, 21 February 2022
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	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
			[[Category:Neurosurgery]]

Chetra.Yean at 19:32, 16 April 2021

2021-04-16T19:32:34Z

← Older revision		Revision as of 12:32, 16 April 2021
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	* Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.		* Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
	** ~~Importing~~ to monitor intraop and post-op urinary output.		** Important to monitor intraop and post-op urinary output.

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Chetra.Yean at 07:10, 11 April 2021

2021-04-11T07:10:44Z

← Older revision		Revision as of 00:10, 11 April 2021
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	* Consider short-to-intermediate acting BB (i.e, esmolol, labelol) for HTN/stimulation not controlled by remi bolus/gtt. HTN will worsen bleeding during ENT portion.		* Consider short-to-intermediate acting BB (i.e, esmolol, labelol) for HTN/stimulation not controlled by remi bolus/gtt. HTN will worsen bleeding during ENT portion.
	* Surgeons will ask for Valsava during the case.		* Surgeons will ask for Valsava during the case.
			* Note down when throat pack is placed in and taken out during case.
	* Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection		* Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

			* Pass OGT to ENT at end of case prior to extubation to suction out any blood that may have dripped down the esophagus and into the stomach.
	* Paralytic reversal (if used).		* Paralytic reversal (if used).
	* Spin back to neutral (particularly, if solo).		* Spin back to neutral (particularly, if solo).