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Managing the Patient with Transsphenoidal Pituitary Tumor

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Managing the Patient with Transsphenoidal Pituitary Tumor Volume 45 & Number 2 & April 2013 101 Managing the Patient With Transsphenoidal 2.5 ANCC Pituitary Tumor Resection Contact Wen Yuan Hours ABSTRACT Patients who undergo transsphenoidal pituitary tumor resection require a multidisciplinary team approach, consisting of a neurosurgeon, an endocrinologist, and nurses. Successful transsphenoidal surgery needs expert nursing care for early identification and prompt treatment of pituitary dysfunction and neurosurgical complications. Pituitary dysfunction includes adrenal insufficiency, diabetes insipidus, syndrome of inappropriate antidiuretic hormone, and cerebral salt wasting syndrome. Neurosurgical complications may include visual disturbance, cerebrospinal fluid leak, subdural hematoma, and epistaxis. Keywords: CSW, DI, endocrinological complications, neurosurgical complications, SIADH, transsphenoidal pituitary tumor resection ituitary tumors account for 10%Y15% of brain hospital stays and reduce healthcare expenditures neoplasms and are usually benign neoplasms while enhancing successful TS pituitary surgery and P of epithelial pituitary tissue (Muh & Oyesiku, quality of life. 2008). Nonfunctional pituitary tumors may result in varying degrees of hypopituitarism or progressive bitemporal visual field loss; hormone-secreting pi- Literature Search Methods tuitary tumors cause pathological syndromes such PubMed, CINAHL, Ovid, and textbooks were searched as acromegaly, Cushing disease (hypercortisolism), using the search terms ‘‘postoperative care following and thyrotoxicosis. Furthermore, the growth of a pi- transsphenoidal pituitary surgery,’’ ‘‘nursing care and tuitary tumor affects adjacent brain structures, caus- transsphenoidal pituitary tumor surgery,’’ ‘‘glucocor- ing neurological deficits such as visual disturbance ticoids replacement in pituitary surgery,’’ and ‘‘glu- (Barkan, Blank, & Chandler, 2008). The incidence cose detection in cerebrospinal fluid leak.’’ To be of surgical complications after transsphenoidal (TS) more comprehensive, the following key words were surgery for pituitary lesions is low if surgery is per- also used in finding more relevant articles: ‘‘pi- formed by an experienced neurosurgeon (Ausiello, tuitary,’’ ‘‘pituitary surgery,’’ ‘‘transsphenoidal surgery,’’ Bruce, & Freda, 2008). The most common compli- ‘‘diabetes insipidus,’’ and ‘‘syndrome of inappropriate cation is diabetes insipidus (DI), especially in pa- antidiuretic hormone.’’ The inclusion criteria were set tients with pituitary microadenomas and Cushing to limit the search to articles from peer-reviewed schol- disease. Other complications include adrenal insuffi- arly journals and textbooks written in English from ciency, syndrome of inappropriate antidiuretic hormone 1998 to 2011 that related to postoperative care after (SIADH), cerebral salt wasting syndrome (CSW), and TS pituitary tumor surgery, including prospective ob- neurosurgical complications such as vision loss, cere- servational studies, systematic reviews, and chapters bral spinal fluid (CSF) leak, subdural hematoma, and from textbooks. Articles from nonscholarly sources or epistaxis (Ausiello et al., 2008). The purpose of this commercial health information sites were excluded. A article is to help nurses to understand the physiology total of 17 articles were found to be eligible under the of the pituitary gland and the importance of early inclusion criteria and most relevant to the topic. Of the identification and prompt treatment of postoperative 17 articles, under ‘‘postoperative care following trans- complications and to familiarize them with instruc- sphenoidal pituitary surgery,’’ only three articles met tions regarding discharge. These measures will shorten inclusion criteria and addressed SIADH and DI, water and electrolyte metabolism disturbances, and man- agement after pituitary tumor surgery. Under ‘‘gluco- Questions or comments about this article may be directed to corticoid replacement in pituitary surgery,’’ the three Wen Yuan, RN ACNP-C MSN, at [email protected]. She is articles were found to be relevant based on the search an Acute Care Nurse Practitioner at Kaiser Permanente Foundation Hospitals, Los Angeles Medical Center, Los Angeles, CA. criteria discussed assessment and management of hypothalamicYpituitaryYadrenal (HPA) axis dysfunc- The author declares no conflicts of interest. tion. Under ‘‘glucose detection in cerebrospinal Copyright B 2013 American Association of Neuroscience Nurses fluid leak,’’ one article published in 2004 assessed DOI: 10.1097/JNN.0b013e3182828e28 the usefulness of glucose detection in diagnosing Copyright © 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited. 102 Journal of Neuroscience Nursing cerebrospinal fluid (CSF) leak. Only two recent arti- cles in the nursing literature met the inclusion criteria Frontline nursing management is under ‘‘nursing care and transsphenoidal pituitary tumor surgery.’’ Eisenberg and Redick (1998) ex- critical in assuring quality care plored a critical pathway as a tool in identifying and managing the two most common potential complica- and optimal patient outcomes tions (DI and CSF rhinorrhea) after TS pituitary tumor for individuals who have resection. Prather, Forsyth, Russell, and Wagner (2003) discussed the successful program at the Uni- undergone transphenoidal versity of Virginia, which mainly consisted of preoper- pituitary tumor resection. ative nursing assessment, patient education, nursing care issues as well as complications monitoring (DI and CSF leak), laboratory follow-up (e.g., serum cortisol level), and staff education in caring for the Physiology of the Pituitary patient undergoing TS surgery. One significant find- The pituitary, a small but important endocrine gland ing of this search was the revelation that there is acting as the ‘‘conductor of the endocrine orchestra’’ limited literature addressing the importance of front- (Ben-Shalomo & Melmed, 2011), is located at the line nursing management in the early postoperative base of the brain. It is connected to the hypothalamus period of TS pituitary surgery. Such management by the pituitary stalk and is divided into two parts, would be expected to have a positive impact on the the anterior and posterior. Its release of hormones is prompt treatment of potentially life-threatening compli- controlled by the hypothalamus (Bougle & Annane, cations. Furthermore, there are few articles that em- 2009). The anterior pituitary gland or adenohypoph- phasize the importance of knowledge-based nursing ysis originates embryologically from Rathke’s pouch education pertaining to the physiology and patho- and produces six hormones (Drouin, 2011), including physiology of the pituitary gland, which, if corrected, luteinizing hormone, follicle-stimulating hormone, pro- would serve to empower nurses in science-based prac- lactin, growth hormone, adrenocorticotropic hormone tice and provide safe, quality patient care. (ACTH), and thyroid-stimulating hormone (Table 1). TABLE 1. Hormones Produced by the Pituitary Gland (Matfin, 2009) Hormone Major Organs Major Physiologic Effects Anterior pituitary gland Growth hormone Liver and adipose tissue Stimulates growth of bone and muscle Promotes protein synthesis and metabolism Decreases carbohydrate metabolism Thyroid-stimulating hormone Thyroid gland Stimulates synthesis of secretion of thyroid hormone Adrenocorticotropic hormone Adrenal cortex Stimulates synthesis and secretion of adrenal cortical hormone Prolactin Mammary gland Stimulates female breast to produce milk Luteinizing hormone Ovaries and testis Females: stimulates corpus luteum development, oocyte release, and estrogen and progesterone production Males: stimulates testosterone secretion and interstitial testes development Follicle-stimulating hormone Ovaries and testis Females: stimulates ovarian maturation and ovulation Males: stimulates sperm production Posterior pituitary gland Antidiuretic hormone Renal collecting tubules Stimulates renal tubule to reabsorb water Oxytocin Ovaries Stimulates uterine contractions and production of milk after birth Copyright © 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited. Volume 45 & Number 2 & April 2013 103 The posterior pituitary gland or neurohypophysis since lack of cortisol can lead to acute adrenal insuf- secretes antidiuretic hormone (ADH) and oxytocin ficiency, which may be a life-threatening condition. (Table 1). Clinical features of adrenal insufficiency may include extreme weakness, fatigue, myalgia, altered mental sta- Postoperative Care tus, hypotension, hyponatremia, hypoglycemia, headache, anorexia, nausea, and vomiting (Aron et al., 2007). There are two postoperative phases of TS surgery, in- Patients with pituitary tumors may undergo a 250-Hg cluding the early phase, which ranges from immedi- cosyntropin stimulation test or a cortisol level check ately after surgery to several weeks thereafter, and the before surgery to assess pituitaryYadrenal function. later phase. This article will focus on the early post- Glucocorticoids must be replaced if there is preoper- operative phase. In the early postoperative phase, as- ative cortisol deficiency (Inder & Hunt, 2002). How- sessing anterior and posterior pituitary dysfunction is ever, most patients with a sizable pituitary lesion are a high priority that includes monitoring pituitaryYadrenal at risk for hypoadrenalism (Ben-Shalomo & Melmed, axis, DI, SIADH, and cerebral salt waste
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