Difference between revisions of "Transphenoidal resection of pituitary tumor"

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(Created page with "{{Infobox surgical case reference | anesthesia_type = General | airway = ETT | lines_access = PIV x 2 Art line | monitors = Standard ASA 5-lead EKG Core temp UOP EEG (opt...")
 
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| anesthesia_type = General
| anesthesia_type = General
| airway = ETT
| airway = ETT
| lines_access = PIV x 2
| lines_access = PIV x 2<Br>Art line
 
| 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
 
| considerations_postoperative = PONV prophylaxis<Br>Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)
5-lead EKG
 
Core temp
 
UOP
 
EEG (optional)
| 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)
}}
}}


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=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Versed


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* N/A


== Intraoperative management ==
== Intraoperative management ==
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* Standard induction
* Standard induction
** Propofol
** Propofol
** Opioid vs Beta Blocker
** Short acting opioid vs beta blocker
*** Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
** Rocuronium
** Rocuronium
*** Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement.
*** Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
* 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.
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=== 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. --> ===


* 180 - place all leads and wiring on one side of the body to facilitate an easier spin
* 180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
* Supine
* Supine
* Arms tucked
* Arms tucked
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=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===


* Propofol gtt (if TIVA, consider EEG monitoring device)
* 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)
* Remifentanil gtt (start with 0.1mcg/kg/min and titrate normal hemodynamic parameters)
* +/- Volatile
* +/- Volatile (can use 0.5 MAC of Sevoflurane requiring less propofol; useful for longer cases when propofol begins to accumulate)
* No steroids; may interfere with AM cortisol measurement the next day
* No steroids unless specifically asked; may interfere with AM cortisol measurement the next day
* ENT will inject lidocaine with epinephrine, watch for IV injection → 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 nose, 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 remi gtt. However, once the stimulation is over, it is typically not very painful so do not overdo it with long-acting opioids.
* Consider BB 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.
* 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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=== 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. --> ===


* Paralytic reversal
* Paralytic reversal (if used).
* Spin back to neutral.
* Spin back to neutral (particularly, if solo).
* Smooth awake extubation (i.e., remi wake-up: decrease to gtt to 0.03-0.05 mcg/kg/min for extubation).
* 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.  
* Avoid positive pressure masking after extubation
* Avoid positive pressure masking after extubation.


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* PACU


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
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=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
** Importing 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). --> ==

Revision as of 14:57, 1 April 2021

Transphenoidal resection of pituitary tumor
Anesthesia type

General

Airway

ETT

Lines and access

PIV x 2
Art line

Monitors

Standard ASA
5-lead EKG
Core temp
UOP
EEG (optional)

Primary anesthetic 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

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

Postoperative

PONV prophylaxis
Iatrogenic diabetes insipidus (monitor intraop and post-op urinary output)

Article quality
Editor rating
In development
User likes
0

Provide a brief summary of this surgical procedure and its indications here.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication

  • Versed

Regional and neuraxial techniques

  • N/A

Intraoperative management

Monitoring and access

  • PIV x 2 (20g for drips, 18g+ for bolus)
  • Art 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.

Induction and airway management

  • Standard induction
    • Propofol
    • Short acting opioid vs beta blocker
      • Can even use remifentanil bolus as induction agent, but consider risk of chest rigidity on induction
    • Rocuronium
      • Induction dose should be sufficient for the entire case as you are also running a remifentanil gtt, which should blunt movement
  • ETT with straight connector
    • Consider mastisol and tegaderm reinforcement of the ETT as you will not have access to the airway.

Positioning

  • 180 - place all leads and wiring on one side of the body prior to induction to facilitate an easier spin
  • Supine
  • Arms tucked
    • Additional IV access site options: saphenous veins

Maintenance and surgical considerations

  • 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)
  • +/- 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
  • 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
  • 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.
  • 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.
  • Foley: yes, for duration of case and to monitor iatrogenic DI caused by the tumor resection

Emergence

  • Paralytic reversal (if used).
  • 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.
  • Avoid positive pressure masking after extubation.

Postoperative management

Disposition

  • PACU

Pain management

  • Tylenol IV
  • Fentanyl (be judicious) as surgeons will likely want a good neuro exam post-op.

Potential complications

  • Iatrogenic diabetes insipidus if vasopressin secreting cells are affected.
    • Importing to monitor intraop and post-op urinary output.

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Chetra Yean, Chris Rishel, Gang Chen and Daniel Diaczok

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