Perioperative Complications Associated with Routine Preoperative Glucocorticoid Use Among Patients undergoing Pituitary Surgery with Normal Preoperative HPA Axis
A Retrospective Cohort Study
DOI:
https://doi.org/10.15605/jafes.040.01.06Keywords:
Pituitary-Adrenal System, Pituitary Gland / Surgery, Postoperative complications, Glucocorticoids, SteroidsAbstract
Objective. This study determined the incidence of perioperative complications associated with routine preoperative glucocorticoid use in patients undergoing pituitary surgery with normal preoperative hypothalamo-pituitary-adrenal axis (HPA axis).
Methodology. From 2011-2021 retrospective chart review, 243 patients undergoing pituitary surgery with normal preoperative HPA axis were analyzed into 2 groups: 1) with preoperative steroids and 2) without preoperative steroids. Development of postoperative complications was subsequently evaluated.
Results. Incidence of primary composite postoperative complications of in-hospital mortality, postoperative infection and postoperative diabetes insipidus (DI) was significantly increased among those who had preoperative steroids compared to those without (58.33% versus 33.33%, p-value 0.004) with an adjusted odds ratio of 2.90 (CI 1.29 to 6.53, p-value 0.010). Among the components of the composite outcome, post-operative DI was statistically higher among those who were given preoperative steroids (52.45% versus 28.21%, p-value 0.006) with an adjusted OR of 3.31 (CI 1.43 to 7.67, p-value 0.005). The incidence of postoperative adrenal insufficiency was similar between the 2 groups (20.15% with steroids versus 8.70% without steroids, p-value 0.258).
Conclusion. Among patients undergoing pituitary surgery with normal preoperative HPA axis, routine preoperative steroids use was associated with an increased risk of composite postoperative complications.
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1. Fridman-Bengtsson O, Höybye C, Porthén L, Stjärne P, Hulting AL, Sunnergren O. Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery. Acta Neurochir (Wien). 2019;161(8):1715–21. https://pubmed.ncbi.nlm.nih.gov/31065892 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616203 https://doi.org/10.1007/s00701-019-03885-6 DOI: https://doi.org/10.1007/s00701-019-03885-6
2. Hout WM, Arafah BM, Salazar R, Selman W. Evaluation of the hypothalamic-pituitary-adrenal axis immediately after pituitary adenomectomy: Is perioperative steroid therapy necessary? J Clin Endocrinol Metab. 1988;66(6):1208-12. https://pubmed.ncbi.nlm.nih.gov/3372683 https://doi.org/10.1210/jcem-66-6-1208 DOI: https://doi.org/10.1210/jcem-66-6-1208
3. Inder WJ, Hunt PJ. Glucocorticoid replacement in pituitary surgery: Guidelines for perioperative assessment and management. J Clin Endocrinol Metab. 2002;87(6):2745-50. https://pubmed.ncbi.nlm.nih.gov/12050244 https://doi.org/10.1210/jcem.87.6.8547 DOI: https://doi.org/10.1210/jcem.87.6.8547
4. Garcia-Luna PP, Leal-Cerro A, Rocha JL, Trujillo F, Garcia-Pesquera F, Astorga R Evaluation of the pituitary-adrenal axis before, during and after pituitary adenomectomy. Is perioperative glucocorticoid therapy necessary? Acta Endocrinol (Copenh). 1990;122(1):83-8. https://pubmed.ncbi.nlm.nih.gov/2154904 https://doi.org/10.1530/acta.0.1220083 DOI: https://doi.org/10.1530/acta.0.1220083
5. Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab. 2017;8(3):33-48. https://pubmed.ncbi.nlm.nih.gov/28377801 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363454 https://doi.org/10.1177/2042018816687240 DOI: https://doi.org/10.1177/2042018816687240
6. Tohti M, Li J, Zhou Y, Hu Y, Yu Z, Ma C. Is peri-operative steroid replacement therapy necessary for the pituitary adenomas treated with surgery? A systematic review and meta analysis. PLoS One. 2015;10(3): e0119621. https://pubmed.ncbi.nlm.nih.gov/25775019 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4361329 https://doi.org/10.1371/journal.pone.0119621 DOI: https://doi.org/10.1371/journal.pone.0119621
7. De Tommasi C, Goguen J, Cusimano MD. Transphenoidal surgery without steroid replacement in patients with morning serum cortisol below 9 μg/dl (250 Nmol/l). Acta Neurochir (Wien). 2012;154(10):1903–15. https://pubmed.ncbi.nlm.nih.gov/22922981 https://doi.org/10.1007/s00701-012-1474-2 DOI: https://doi.org/10.1007/s00701-012-1474-2
8. Merkler AE, Saini V, Kamel H, Stieg PE. Preoperative steroid use and the risk of infectious complications after neurosurgery. Neurohospitalist. 2014;4(2):80-5. https://pubmed.ncbi.nlm.nih.gov/24707336 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975792 https://doi.org/10.1177/1941874413510920 DOI: https://doi.org/10.1177/1941874413510920
9. Ismael H, Horst M, Farooq M, Jordon J, Patton JH, Rubinfeld IS. Adverse effects of preoperative steroid use on surgical outcomes. Am J Surg. 2011;201(3):305–8. https://pubmed.ncbi.nlm.nih.gov/21367368 https://doi.org/10.1016/j.amjsurg.2010.09.018 DOI: https://doi.org/10.1016/j.amjsurg.2010.09.018
10. Hattori Y, Tahara S, Aso S, et al. Pituitary surgery's epidemiology using a national inpatient database in Japan. Acta Neurochir (Wien). 2020;162(6):1317–23. https://pubmed.ncbi.nlm.nih.gov/32125502 https://doi.org/10.1007/s00701-020-04270-4 DOI: https://doi.org/10.1007/s00701-020-04270-4
11. Faltado AL, Macalalad-Josue AA, Li RJS, Quisumbing JPM, Yu, MGY, Jimeno C. Factors associated with postoperative diabetes insipidus after pituitary surgery. Endocrinol Metab (Seoul). 2017; 32(4):426-33. https://pubmed.ncbi.nlm.nih.gov/29199401 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5744728 https://doi.org/10.3803/EnM.2017.32.4.426 DOI: https://doi.org/10.3803/EnM.2017.32.4.426
12. Stryja J, Sandy-Hodgetts K, Collier M, et al. Surgical site infection: Prevention and Management across health-care sectors. J Wound Care. 2020;29(Sup2b):S1-72. https://pubmed.ncbi.nlm.nih.gov/32067551 https://doi.org/10.12968/jowc.2020.29.Sup2b.S1 DOI: https://doi.org/10.12968/jowc.2020.29.Sup2b.S1
13. Kazlauskaite R, Evans AT, Villabona CV, et al. Corticotropin tests for hypothalamic–pituitary–adrenal insufficiency: A metaanalysis. J Clin Endocrinol Metab. 2008;93(11):4245-53. https://pubmed.ncbi.nlm.nih.gov/18697868 https://doi.org/10.1210/jc.2008-0710 DOI: https://doi.org/10.1210/jc.2008-0710
14. Turina M, Miller FN, Tucker CF, Polk HC. Short-term hyperglycemia in surgical patients and a study of related cellular mechanisms. Ann Surg. 2006; 243(6):845–53. https://pubmed.ncbi.nlm.nih.gov/16772788 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570574 https://doi.org/10.1097/01.sla.0000220041.68156.67 DOI: https://doi.org/10.1097/01.sla.0000220041.68156.67
15. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2018; 71(19), e127-248. https://pubmed.ncbi.nlm.nih.gov/29146535 https://doi.org/10.1016/j.jacc.2017.11.006 DOI: https://doi.org/10.1161/HYP.0000000000000076
16. Roshanov PS, Sheth T, Duceppe E, et al. Relationship between perioperative hypotension and perioperative cardiovascular events in patients with coronary artery disease undergoing major noncardiac surgery. Anesthesiology. 2019;130(5):756-66. https://pubmed.ncbi.nlm.nih.gov/30870165 https://doi.org/10.1097/ALN.0000000000002654 DOI: https://doi.org/10.1097/ALN.0000000000002654
17. Rajaratnam S, Seshadri MS, Chandy MJ, Rajshekhar V. Hydrocortisone dose and postoperative diabetes insipidus in patients undergoing transsphenoidal pituitary surgery: A prospective randomized controlled study. Br J Neurosurg. 2003;17(5):437-42. https://pubmed.ncbi.nlm.nih.gov/14635749 https://doi.org/10.1080/02688690310001611233 DOI: https://doi.org/10.1080/02688690310001611233
18. Aubry R, Nankin H, Moses A, Streeten D. Measurement of the osmotic threshold for vasopressin release in human subjects, and its modification by cortisol. J Clin Endocrinol Metab. 1965;25(11):1481-92. https://pubmed.ncbi.nlm.nih.gov/5843703 https://doi.org/10.1210/jcem-25-11-1481 DOI: https://doi.org/10.1210/jcem-25-11-1481
19. Hattori Y, Tahara S, Aso S, et al. Prophylactic steroid administration and complications after transsphenoidal pituitary surgery: A nationwide inpatient database study in Japan. Br J Anaesth. 2021;127(2):e41–3. https://pubmed.ncbi.nlm.nih.gov/33992400 https://doi.org/10.1016/j.bja.2021.04.006 DOI: https://doi.org/10.1016/j.bja.2021.04.006
20. Bhansali A, Dutta P, Bhat MH, Mukherjee KK, Rajput R, Bhadada S. Rational use of glucocorticoid during pituitary surgery - A pilot study. Indian J Med Res. 2008;128(3):294-9. https://pubmed.ncbi.nlm.nih.gov/19052341
21. Lee H, Yoon H, Kim JH, Kim YH, Park H. Comparison of intraoperative cortisol levels after preoperative hydrocortisone administration versus placebo in patients without adrenal insufficiency undergoing endoscopic transsphenoidal removal of nonfunctioning pituitary adenomas: A double-blind randomized trial. J Neurosur. 2021;134(2):526-34. https://pubmed.ncbi.nlm.nih.gov/31978882 https://doi.org/10.3171/2019.11.JNS192381 DOI: https://doi.org/10.3171/2019.11.JNS192381
22. Elston MS, Conaglen HM, Hughes C, Tamatea JAU, Meyer-Rochow GY, Conaglen JV. Duration of cortisol suppression following a single dose of dexamethasone in healthy volunteers: A randomised double-blind placebo-controlled trial. Anaesth Intensive Care. 2013;41(5):596–601. https://pubmed.ncbi.nlm.nih.gov/23977910 https://doi.org/10.1177/0310057X1304100504 DOI: https://doi.org/10.1177/0310057X1304100504
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