Pre-operative examination
1. Pre-operative general routine examination items (applicable to all neurosurgical elective surgery patients)
Six labs: routine blood, urine routine, liver and kidney complete, coagulation I, ABO blood group + Rh factor, transfusion eight; electrocardiogram; chest X-ray front and side. Older patients need to check echocardiography and pulmonary function, and even respiratory sleep monitoring and blood gas analysis.
2. Pre-operative examination of pituitary adenoma
Increase: blood PRL; GH; F; A gong I or A gong II; ACTH; FSH, LH, E2 (female), T (male); 24-hour urine UFC. increase in Cushing’s disease: large and small dose dexamethasone suppression test or combined large and small dose suppression test. Dexamethasone suppression test (control: 24-hour urine from 6:00 a.m. to 6:00 a.m. the next day, 24-hour UFC; small dose dexamethasone suppression test: 0.5 mg dexamethasone each from 06:00-12:00-18:00-24:00. (At the same time from 6:00 to 6:00 of the next day to stay 24 hours urine, check the 24-hour UFC; high-dose dexamethasone suppression test: first according to the above-mentioned method to stay control 24 hours UFC, and then start taking the drug, and at the same time to stay 24 hours urine to check the UFC, the method is the same as the small-dose suppression test, but each oral dose of dexamethasone 2mg). Combined large and small dose dexamethasone suppression test (24 urine samples were taken on day 1 to check the control UFC; on days 2 and 3, the dose was taken according to the small dose dexamethasone suppression test, and on day 3, the dose was taken and urine was also kept; on days 4 and 5, the dose was taken according to the large dose dexamethasone suppression test, and on day 5, both the dose and urine were kept). For growth hormone adenoma, echocardiography, pulmonary function, blood gas analysis if necessary, and IGF-1 (insulin-like growth factor-1) should be added to the blood sample, and the growth hormone glucose suppression test should be performed (0′ blood sample for control GH and Glu, 30′, 60′, 120′, 180′ after 100g of oral glucose). For PRL adenoma, additional bromocriptine suppression tests (five tests) are required: control 0′, control 0′, control Glu, control Glu, control GH and Glu. ‘ Blood was drawn for control PRL and 2.5mg of bromocriptine was drawn for PRL 2, 4, 6 and 8 hours after oral administration.
3. frontal and lateral X-rays of the head, purpose: to see the size and destruction of the pterygoid saddle, and sometimes for reference when C-arm X-ray monitoring is needed intraoperatively.
Ask for an ophthalmology consultation, purpose: to check visual acuity and visual field.
Pituitary MRI plain scan + enhancement. Individual pituitary microadenomas require request for dynamic enhancement MRI of the pituitary gland. No need to recheck for clearer external MRI. Previous MRI is valid for 3 months and requires reexamination beyond 3 months.
Appointment for neuronavigation MRI: For patients with recurrent pituitary adenomas after previous transsphenoidal surgery, those whose anatomical landmarks are no longer clear, invasive pituitary adenomas, microadenomas located laterally or deeply in the pituitary gland, pituitary adenomas with poor pneumatization of the pterygoid sinus, abnormal thickening of the skull base, bilateral narrowing of the internal carotid artery spacing and/or severe deviation of the nasal septum. This exam site is a scan of the entire skull, with a note thin layer scan to the nasal tip and nerve navigation inscription.
Preoperative medical advice
1, 1-3 days before surgery: oral antimicrobial; chloramphenicol eye drops (or furosemide nasal drops) nasal drops, tid; prednisone 5 mg, tid (prednisone is not used preoperatively in Cushing’s disease).
2, 1 day before surgery: nasal hair clipping; blood RBC 800ml; intraoperative with hydrocortisone 100mg (exception for Cushing’s disease), lisdexamfetamine 2ku or caroxolone sodium 20mg, 1 intravenous dosage of antimicrobial (ceftizoxime sodium / fudaxin / rocephin / cefotaxime sodium, etc.); disposable catheterization kit; drug enema and prescribe glycerol enema 110mL/branch.
For transcranial surgery of pituitary adenoma or other saddle area lesions, preoperative oral hormones are also required according to the above principles, and oral sodium valproate extended release 500mg bid.
Postoperative medical advice
1, care and monitoring: flat position for 1 day to 1 week (postoperative pillow can be padded for those who have no cerebrospinal fluid leak, and can sit and stand and move slightly on the ground on the second postoperative day; those who have cerebrospinal fluid leak but saddle base bone reconstruction are the same as those who have no CSF leak; those who have severe cerebrospinal fluid leak lie flat for 3 days to 1 week after surgery); fasting and water fasting for 6 to 8 hours, oxygen inhalation for 1 to 3 days, continuous ECG, oxygen and blood pressure monitoring for 1 to 3 days. The first 3 days of postoperative period, routine check of blood and kidney qdX3 in the morning, additional blood tests on the first day of postoperative period, and recheck of blood electrolytes on the day before or the morning of discharge, and discharge only after electrolytes are normal. Cushing’s patients should have their blood F checked on postoperative day 1 and 24-hour urine should be kept for UFC. Polydipsia patients should have their electrolytes checked daily, 2-3 times a day if necessary. Depending on the type of pituitary adenoma, the relevant hormones are routinely rechecked 3-5 days after surgery. 2-7 days later, the nasal oil gauze is removed (2-3 days for those without CSF leakage, 3-7 days for those with leakage, depending on the intraoperative repair of the leakage).
2, daily large liquid volume of about 1000ml, including potassium chloride 3-4.5g, sodium chloride 4-6g, vitamin C 2g.
3.Other pituitary tumors outside Cushing: hydrocortisone succinate 100mg, into the liquid, Q12h×2~3 days, after 3 days, change to oral prednisone 5mg, tid, then gradually reduce the dosage, reduce the dosage once every 1 week or so, and strive to stop the drug completely around 1~1.5 months. The dose can be reduced by 5mg, tidX1 week→5mg,bidX1 week→5mg,qdX1 week→2.5mg,qdX1 week→discontinuation, and return to the original dose if there is discomfort and hypopituitarism performance during the reduction. Cushing’s patients with postoperative hypopituitarism also need to add hormones, and blood should be drawn for cortisol before adding hormones. Dexamethasone 5~10mg into the pot q12h can also be used for pituitary tumor craniotomy.
4, sufficient amount of prophylactic antimicrobial: intravenous 3 days to 7 days (3 days for those without cerebrospinal fluid leakage, 1 week for those with cerebrospinal fluid leakage), then change to oral antimicrobial, a total of 1 to 2 weeks.
5.Hemostatic drugs: Lithopodium 1-2ku, into the pot (injection), q12h; or caroxolone sodium 40mg, iv q12h. discontinue after 1 day.
6.Stress ulcer prevention drugs: Famotidine 20mg, or Omeprazole 40mg, into the pot (injection), q12h. change to oral after 3 days.
7.Patients with polyuria (urine volume >200mL per hour, >3000mL per day), first-line drugs: painkine (carbamazepine 100mg#) 200mg, TID; dihydrocortisone 50mg, tid~bid. second-line drugs: mydriasis 0.05mg~0.1mg, BID~TID. after normal urine volume, instruct to gradually stop the drug after discharge (reduce the dose once in about 1 week. (first reduce the noon, then reduce the evening, and finally reduce the morning, and strive to 1 ~ 1.5 months to stop.) The drug will be discontinued in 1 to 1.5 months.
8.People with preoperative vision loss can use neurotrophic drugs appropriately.
9.Some people with hypothyroidism need to supplement thyroxine, and it is advisable to start with small doses of supplementation, as oversupply may cause accelerated heart rate.
In general, patients with pituitary adenoma after transsphenoidal surgery, such as nausea and vomiting, should not rashly use antiemetic drugs only, it is advisable to first consider water and electrolyte disorders, need to urgently check the blood electrolytes. If postoperative patients with Cushing’s disease have heartburn, they should also consider the possibility of hypopituitarism and add hormones promptly.
All the above doses are adult doses. Other medications will be determined on a case-by-case basis.
Discharge instructions
Several key points.
1. Pay attention to the water and electrolyte balance, and come to our hospital or local hospital in time if there is any discomfort.
2, long-term follow-up and regular review.
3, discharge with medication: prednisone (need to emphasize the gradual reduction!) , furosemide nasal drops, oral antimicrobials, anti-diuretic drugs, neurotrophic drugs, etc., prescribed on a case-by-case basis.
4, combined with other diseases such as diabetes, hypertension, heart disease and other conditions, the relevant discharge with drugs and recommendations.