Pituitary surgery

Intra-op issues:

Pituitary tumour

· Mass effects: hypothalamus, pituitary, vision

· Metastases: rarely relevant

· Medications: hormone replacement

· Metabolic: macro vs microadenoma

FESS

Airway:

· Problem: remote, shared, bloody

· Solution: oral RAE, throat pack, suction at end

Bleeding:

· Surgeon: vasoconstrictor -> ↑BP, ↑HR, arrhythmias

· Anaesthesia: head up, ↓Paw, ↓CO2, ↓HR, ↓BP, smooth emergence

Head up:

· Cerebral hypoperfusion = A-line + metaraminol infusion

Neuro

· Require immobility = remifentanil ± paralysis

· Require smooth emergence without CPAP (dural breach)

· Vessel injury = massive bleeding + tight brain

Endocrine dysfunction

· Central DI in 40%

· SIADH (delayed)

· Adrenal insufficiency

Surgical complications

Of dural breach:

· CSF leak

· Pneumocephalus (CPAP relatively contraindicated)

· Meningitis

Other:

· Bleeding

· Stroke

· Hypothalamic injury