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Rational use of glucocorticoid during pituitary surgery – A pilot study
Reprint requests: Prof. Anil Bhansali, Department of Endocrinology, Postgraduate Institute of Medical Education & Research Chandigarh 160 012, India e-mail: anilbhansali_endocrine@rediffmail.com
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Received: ,
Abstract
Background & objectives:
The conventionally used perioperative glucocorticoid replacement protocol in patients with pituitary tumours is far from optimal. In this study we evaluated the validity of a modified protocol for perioperative glucocorticoid replacement in non-functioning pituitary macroadenomas.
Methods:
A total of 24 consecutive patients with non functioning pituitary macroadenomas were included in this interventional study. Patients with a pre-operative 0800 h cortisol of =350 nmol/l (= 12.6 μg/dl) did not receive glucocorticoid replacement during perioperative (d0-d-2) period, while those with =100nmol/l (= 3.6 μg/dl) received gluocorticoid replacement. Those patients with 0800 h cortisol value between >100-349 nmol/l (> 3.6-12.6 μg/dl) required them to undergo an insulin induced hypoglycaemia (IIH). In response to IIH, patients with a peak cortisol of <550 nmol/l (< 19.8 μg/dl) received glucocorticoid replacement. Post-operatively, patients on day 3 with 0800 h cortisol of =100 nmol/l (=3.6 μg/dl) received hydrocortisone 10 mg/m2 per day; those between >100-449nmol/l (>3.6-16μg/dl) received hydrocortisone replacement only if they had symptoms of adrenal insufficiency (AI) or during stress; while patients with =450 nmol/l (=16.0 μg/dl) did not receive any glucocorticoid replacement. Retesting was done at 12 wk in 23 subjects based on the algorithm.
Results:
Pre-operatively, 8 (35%) patients were hypocortisolic and received glucocorticoid supplementation, thereby sparing 15 (65%) subjects from glucocorticoid replacement. On d3 of surgery, 13 (57%) patients were hypocortisolic, but only 6 with serum cortisol of =100 nmol/l (= 3.6 μg/dl), had symptoms and were substituted with glucocorticoid. Remaining seven patients, with serum cortisol between >100-349 nmol/l (> 3.6-12.6 μg/dl), were asymptomatic and advised glucocorticoid support only during stress but none required. Overall, 17 (74%) patients were spared from unnecessary glucocorticoid support. At 12 wk, 13 (57%) patients were hypocortisolic and only 6 either with serum cortisol level of =100 nmol/l (=3.6 μg/dl) or symptomatic for AI received glucocorticoids. Post-operative complications including diabetes insipidus and CSF leak remarkably decreased.
Interpretation & conclusions:
The protocol used was safe and spared unnecessary use of glucocorticoids peri- and post-operatively. However, more number of patients are to be studied tosubstantiate the validity of this protocol.
