Anesthetic and critical care management of patients undergoing pituitary surgery

Patients with tumors of the pituitary gland represent a heterogeneous yet commonly encountered neurosurgical population. Optimal anesthetic care requires an understanding of the complex pathophysiology secondary to each patient's endocrinological disease. Although patients presenting with Cushing's disease and acromegaly have unique manifestations of endocrine dysfunction, all patients with tumors of the pituitary gland require meticulous preoperative evaluation and screening. There are many acceptable strategies for optimal intraoperative anesthetic management; however, the selection of anesthetic agents should be tailored to facilitate surgical exposure, preserve cerebral perfusion and oxygenation, and provide for rapid emergence and neurological assessment. A rapid emergence from anesthesia is particularly important, as an early neurological assessment is necessary to evaluate cranial nerve integrity. In the postoperative period, careful monitoring of fluid balance and serum sodium is essential to the early diagnosis of diabetes insipidus (DI) and the syndrome of inappropriate anti-diuretic hormone (SIADH) secretion. DI is most often transient, but can require medical therapy. SIADH has a number of treatment options and decisions should be based upon the patient's status. A thorough understanding of the preoperative assessment, intraoperative management, and potential complications is fundamental to successful perioperative patient care and avoidance of morbidity and mortality.