Rational use of glucocorticoid during pituitary surgery--a pilot study

• Published in: Indian journal of medical research (New Delhi, India : 1994) Vol. 128; no. 3; p. 294
• Main Authors: Bhansali, Anil, Dutta, Pinaki, Bhat, M H, Mukherjee, K K, Rajput, Rajesh, Bhadada, Sanjay
• Format: Journal Article
• Language: English
• Published: India Medknow Publications and Media Pvt. Ltd 01.09.2008; Medknow Publications & Media Pvt. Ltd
• Subjects: Adenoma - drug therapy; Adenoma - surgery; Adult; Care and treatment; Combined Modality Therapy; Corticosteroids; Diagnosis; Dosage and administration; Drug Monitoring; Female; Glucocorticoids - administration & dosage; Glucocorticoids - adverse effects; Glucocorticoids - blood; Health aspects; Humans; Hydrocortisone - administration & dosage; Hydrocortisone - adverse effects; Hydrocortisone - blood; Hypophysectomy; Male; Middle Aged; Pilot Projects; Pituitary gland tumors; Pituitary Neoplasms - drug therapy; Pituitary Neoplasms - surgery; Postoperative Complications; Prospective Studies; Treatment Outcome; India
• ISSN: 0971-5916

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. 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 > or = 350 nmol/l (> or = 12.6 microg/dl) did not receive glucocorticoid replacement during perioperative (d(0)-d-(2)) period, while those with < or = 100 nmol/l (< or = 3.6 microg/dl) received glucocorticoid replacement. Those patients with 0800 h cortisol value between > 100-349 nmol/l (> 3.6-12.6 microg/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 microg/dl) received glucocorticoid replacement. Post-operatively, patients on day 3 with 0800 h cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl) received hydrocortisone 10 mg/m(2) per day; those between > 100-449 nmol/l (> 3.6-16 microg/dl) received hydrocortisone replacement only if they had symptoms of adrenal insufficiency (AI) or during stress; while patients with > or = 450 nmol/l (> or = 16.0 microg/dl) did not receive any glucocorticoid replacement. Retesting was done at 12 wk in 23 subjects based on the algorithm. Pre-operatively, 8 (35%) patients were hypocortisolic and received glucocorticoid supplementation, thereby sparing 15 (65%) subjects from glucocorticoid replacement. On d(3) of surgery, 13 (57%) patients were hypocortisolic, but only 6 with serum cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl), had symptoms and were substituted with glucocorticoid. Remaining seven patients, with serum cortisol between >100-349 nmol/l (> 3.6-12.6 microg/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 < or = 100 nmol/l (< or = 3.6 microg/dl) or symptomatic for AI received glucocorticoids. Post-operative complications including diabetes insipidus and CSF leak remarkably decreased. The protocol used was safe and spared unnecessary use of glucocorticoids peri- and post-operatively. However, more number of patients are to be studied to substantiate the validity of this protocol.