Transsphenoidal Pituitary Resection
Patient phenotype
Pituitary adenoma (functional: prolactin, GH/acromegaly, ACTH/Cushing's, TSH; non-functional: mass effect). Acromegaly = airway concerns. Cushing's = HTN, glucose, OSA. Apoplexy = emergency.
Procedure
Endoscopic endonasal approach — transnasal, through sphenoid sinus, into sella. Surgeon + ENT often combined. ~2-4 hours. Supine, head slight extension. Tumor curetted out under endoscope.
Anesthetic plan
GETA with reinforced or RAE oral tube (positioned away from surgical field). A-line for HTN management. Throat pack placed (REMOVE before extubation — HARD STOP). Smooth emergence (avoid coughing — CSF leak risk).
Setup
- ·A-line
- ·1-2 PIVs
- ·Reinforced or south-pointing RAE oral ETT
- ·Throat pack + reminder to remove (verbal + visual)
- ·Stress-dose hydrocortisone if Cushing's, ACTH-suppressive, or hypopituitary
- ·DDAVP available (DI postop)
- ·Forced air warmer
Biggest concerns by phase
Acromegaly airway
Macroglossia, prognathism, vocal cord enlargement, OSA, glottic narrowing. Difficult mask + intubation. Have video laryngoscope, awake fiberoptic backup. Smaller tube than expected.
Endocrine status — multiple deficiencies common
Hypopituitarism: cortisol, T4, GH, gonadotropins. Stress-dose hydrocortisone preop if any concern. Recent cortisol/TSH levels. Cushing's-specific: BP, glucose.
Throat pack — count + remove
ENT places gauze pack in oropharynx to absorb blood. MUST be removed before extubation (death by aspiration documented). Verbal time-out + sign on monitor + visual confirmation.
Hemodynamic management for surgical field
Surgeon wants quiet field — modest hypotension (MAP 65-75). Use volatile + remi infusion + vasodilator (nitroglycerin or nicardipine PRN). Avoid hypertension (bleeding obscures field).
Carotid or cavernous sinus injury — rare but catastrophic
Sphenoid + sella adjacent to ICA. Injury → massive bleeding + stroke. Have blood available, alert team, surgical pause for tamponade.
Smooth emergence — CSF leak risk
Coughing/bucking → ICP spike → CSF leak through surgical defect. Deep extubation if airway favorable, or remi/dex-based smooth emergence. Antiemetic prophylaxis.
Diabetes insipidus (DI) detection
Posterior pituitary disruption → ADH deficiency → DI: high UOP (> 250 mL/h × 2h), dilute urine (SG < 1.005), rising serum Na. Treatment: DDAVP + free water replacement.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
45-yo M with acromegaly, fasting glucose 240, OSA on CPAP, GH-secreting macroadenoma. Transsphenoidal resection. Walk through airway plan + endocrine considerations.
What an examiner probes for
- ▹Recognizes difficult airway: video laryngoscope, awake FOI backup, smaller tube
- ▹Continues steroids + verifies cortisol
- ▹Glucose management with insulin scale
- ▹Throat pack + extubation strategy
- ▹Postop DI surveillance
Sources
- Cottrell Neuroanesthesia 6e Ch 17
- AANS Pituitary Surgery Guidelines
Anatomy reference
Sourced reference images. 4 matches for "brain pituitary sella sphenoid".
