Acromegaly

Pituitary hormones:

· ACTH

· TSH

· GH

· FSH and LH

· PRL

Posterior

· ADH

· Oxytocin

Mass	· Risk of pituitary insufficiency · Need test ± replacement · Especially glucocorticoid, thyroid hormones
Metastases	· N/A
Metabolic	· Growth hormone -> see below
Medication	· Somatostatin · Bromocriptine -> postural hypotension

Airway	· Enlarged and distorted soft tissues · Narrowed subglottis ->Difficult bag-mask ventilation. Need large mask and OPA. ->Difficult intubation. Need VL with large blades but smaller ETT.
Breathing	· OSA ->Awake extubation ->Care with opioids
Cardiovascular	· HTN · Ischaemic heart disease · Cardiomyopathy ->Need arterial line ->Need CVS stability
Endocrine	· T2DM · Pituitary dysfunction · Central diabetes insipidus -> desmopressin ->Need regular ABG intra-op ->Need regular bloods post-op
Musculoskeletal	· Enlarged and distorted skeleton (e.g. kyphosis) ->Care with patient positioning · Neurovascular compression syndromes (e.g. ulnar artery in 50%) ->Avoid radial arterial line

Airway

· Remote

· Shared

· Difficulty

->Must secure properly

Microsurgery

· Requires immobility

· Rx remifentanil infusion + atracurium infusion

Post-op CPAP

· Benefit (OSA)

· Harm (pneumocephalus)

Analgesia

· Benefit (relieve suffering)

· Harm (OSA)