Excision of Pituitary Tumor, Transnasal

Excision of Pituitary Tumor, Transnasal (CPT 61548) 

General: This procedure involves resection of a pituitary tumor. Patients symptoms may be related to production of excess hormones (microadenoma) or mass effect (macroadenoma). Common symptoms include amenorrhea, infertility, galactorrhea, acromegaly (potential intubation problems), hypertension, Cushings syndrome, headache and visual field defects.
Preop: Place IV in left hand. 1-2 mg of midazolam after IV has been started. Remind patient of potential blood in pharynx (spit up, don’t swallow). Remember potential for airway problems, hemodynamic lability and electrolyte disturbances.
Monitors: Blood pressure cuff on right arm, pulse oximeter probe and neuromuscular monitors on left hand/wrist. Arterial line only if indicated by patient’s medical condition.
Anesthesia: Any general anesthesia technique may be used for these operations. Administer 1-2 gm Cefazolin, and 100 mg hydrocortisone IV. Patients with Cushings syndrome should be administered 1 mg of decadron instead of hydrocortisone (verify with surgeon). After induction of anesthesia, and intubation, position ET tube to the left hand side of mouth. Tape to mandible (nothing on upper lip). Tape eyes carefully with Tegaderm, particularly the medial canthus (to protect from prep solution). Insert orogastric tube and/or throat pack (used to reduce amount of blood in esophagus and stomach at the end of the case). Insert esophageal temperature probe orally. Foley catheters are not used routinely. Ventilate to normocapnia. Table turned 90 degrees to the right, left arm toward anesthesia. Patient may be turned into left lateral position for intrathecal catheter placement (spinal drain). Spinal drain passed under patient to anesthesia (confirm that stopcock is closed), and patient then turned supine to sitting position. Head placed in Mayfield pins (stimulating). Fluoroscope positioned for lateral head images (points right at anesthesia). Abdomen (for harvesting fat) and face prepped. Afrin nasal spray will be administered. Surgical approach to pituitary either with a speculum or an endoscope. During resection of pituitary tumor surgeon may ask you to inject sterile preservative free saline (double check) into the spinal drain (moves pituitary toward surgeon). At the end, sella will be filled with fat, and covered with fibrin glue. Nose will be packed at the end of the operation. Nasal packing will be removed just before extubation. Reverse residual neuromuscular relaxation after Mayfield pins have been removed. Aspirate and remove orogastric tube and/or throat pack before extubation. Extubate after patient follows commands. Spinal drain may or may not be removed (ask surgeon).
Potential complications: Bleeding from cavernous sinus or carotid arteries. “High venous pressure” bleeding intraoperatively. May be due to compressed IJ due to head position. Make sure there are no treatable causes for increased venous pressure, e.g. high intrathoracic pressure, coughing or straining against ventilator. Try reducing blood pressure, but maintain adequate CPP. Diabetes Insipidus can occur, but is usually in the post-operative phase.
Recovery: Recovery room. Postoperative nausea/vomiting is common if there is blood in the stomach. 

Last revised 05/2013 Talke 

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This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.