Transphenoidal resection of pituitary tumor

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)
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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

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
  • Opioid vs Beta Blocker
  • 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 to facilitate an easier spin
• Supine
• Arms tucked
  • Additional IV access site options: saphenous veins

Maintenance and surgical considerations

• Propofol gtt (if TIVA, consider EEG monitoring device)
• Remifentanil gtt (start with 0.1mcg/kg/min and titrate)
• +/- Volatile
• No steroids; may interfere with AM cortisol measurement the next day
• ENT will inject lidocaine with epinephrine, watch for IV injection → tachycardia, hypertension
• 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.
• Consider BB 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
• Spin back to neutral.
• Smooth awake extubation (i.e., remi wake-up: decrease to gtt to 0.03-0.05 mcg/kg/min for extubation).
• Avoid positive pressure masking after extubation

Postoperative management

Pain management

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

Procedure variants

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