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Table of Contents    
LETTERS TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1833-1834

An easy mnemonic to remember anesthetic considerations during transsphenoidal surgeries


1 Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anesthesia, Government Medical College, Jammu and kashmir, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Pallavi Bloria
Department of Anesthesia, Government Medical College, Jammu and kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.246280

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How to cite this article:
Bloria SD, Bloria P. An easy mnemonic to remember anesthetic considerations during transsphenoidal surgeries. Neurol India 2018;66:1833-4

How to cite this URL:
Bloria SD, Bloria P. An easy mnemonic to remember anesthetic considerations during transsphenoidal surgeries. Neurol India [serial online] 2018 [cited 2018 Dec 14];66:1833-4. Available from: http://www.neurologyindia.com/text.asp?2018/66/6/1833/246280


The endonasal approach for pituitary surgeries is a very popular approach in view of better cosmesis, lesser incidence of diabetes insipidus, and lesser incidence of dental and nasal complications.[1],[2] Intraoperative management of these surgeries has various special considerations and can prove to be challenging for anesthesiologists.[3],[4],[5]

Mnemonics are simple techniques to help us remember things and have been applied in many domains of life. LEMON [L: Look externally (facial trauma, large incisors, beard or moustache, large tongue; E: Evaluate the 3-3-2 rule, that is, incisor distance: 3 finger breaths (FB), hyoid-mental distance: 3 FB, and thyroid-to-mouth distance: 2 FB; M: Mallampati score > 3; O: Obstruction, that is, the presence of any condition like epiglotitis, peritonsillar abscess, trauma; N: Neck mobility (limited neck mobility)] for airway assessment and MOANS (M: Mask seal difficult due to receding mandible, syndrome with facial anomalies, burns, strictures, etc. O: Obesity, upper airway Obstruction; A: Advanced age; N: No teeth; S: Snorer) to predict difficult facemask ventilation, are examples of mnemonics used in anesthesia on a routine basis.

We propose the mnemonic “SPHENOIDAL” as a guide for anesthetic management for transsphenoidal pituitary surgeries, guiding the anesthesiologist intraoperatively during the important steps of surgery. This is just meant to be a guide to remind the anaesthesiologist intraoperatively about special considerations at various steps of surgery and definitely not a replacement for a well-performed preanesthetic evaluation. Also, there are various manifestations of pituitary tumors that affect the intraoperative management in addition to the considerations described below:

1. S – Steroid supplementation

Explanation: Intraoperatively, the anaesthesiologist must know about the need to administer steroids. Historically, these patients were administered “stress doses” of steroids perioperatively. Presently, different institutions have developed local protocols about the need to administer steroids to these patients perioperatively. For patients with proven adrenocorticotropic hormone (ACTH) deficiency preoperatively [usually based on the response to a short ACTH 1–24 (Synacthen) test], 48 h of supraphysiological glucocorticoid therapy should be administered perioperatively (e.g., hydrocortisone 50 mg every 8 h on day 0, 25 mg every 8 h on day 1, and 25 mg at 08.00 h on day 2). For patients with an intact hypothalamo-pituitary function preoperatively, and in whom selective adenomectomy is possible, perioperative glucocorticoids are not necessary.

2. P – Packing of the oropharynx

Explanation: A pharyngeal pack is inserted after intubation to prevent blood and debris from entering the stomach to prevent nausea, vomiting, and aspiration in the postoperative period.

3. H – Hormone levels/hypercarbia

Explanation: These patients must be euthyroid before they undergo surgery. In addition, the levels of other pituitary hormones must also be determined. The patients on preoperative hormone supplementation should continue the same perioperatively. Also, controlled hypercarbia up to 60 mmHg has been described as an effective measure to lower the tumor into the surgical field intraoperatively without any ill effects.[3]

4. E – Endotracheal tube to be fixed to the opposite side

Explanation: The endotracheal tube and the anesthesia circuit should be on the opposite side to that of the surgeon's dominant hand.

5. N – Normothermia

Since early awakening is the norm in most of these patients, these patients must be kept normothermic intraoperatively.

6. O – Observe for hemodynamic changes during tumor dissection

Explanation: Activation of the trigeminocardiac reflex during the dissection of tumor can precipitate bradycardia and even asystole.

7. I – Infiltration of nasal mucosa

Explanation: Performed by the surgeon to achieve a bloodless field, this evokes a very strong sympathetic response and can result in a hypertensive crisis and myocardial infarction.[4] The anesthesiologist must be aware of this complication, and drugs to deal with it must be ready.

8. D – Diabetes insipidus

Explanation: Pituitary surgeries are associated with a high incidence of water and electrolyte abnormalities. One must keep an eye on the intraoperative urine output, and sodium levels must be checked at regular levels.

9. A – Airway

Explanation: Patients with acromegaly and Cushing's disease can prove to be difficult to mask-ventilate and intubate.

10. L – Lumbar drain

Explanation: It is used to manipulate the cerebrospinal fluid (CSF) pressure by the injection of saline or removal of CSF. Sometimes, air is inserted intrathecally through a lumbar drain, to increase the CSF pressure and push the tumor down into the surgical field. Nitrous oxide should be discontinued at this time to prevent expansion of the intracranial air space.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: An early experience. Surg Neurol 1997;47:213-22.  Back to cited text no. 1
    
2.
Shah S, Har-El G. Diabetes insipidus after pituitary surgery: Incidence after traditional versus endoscopic transsphenoidal approaches. Am J Rhinol 2001;15:377-9.  Back to cited text no. 2
    
3.
Korula G, George SP, Rajshekhar V, Haran RP, Jeyaseelan L. Effect of controlled hypercapnia on cerebrospinal fluid pressure and operating conditions during transsphenoidal operations for pituitary macroadenoma. J Neurosurg Anesthesiol 2001;13:255-9.  Back to cited text no. 3
    
4.
Chelliah YR, Manninen PH. Hazards of epinephrine in transsphenoidal pituitary surgery. J Neurosurg Anesthesiol 2002;14:43-6.  Back to cited text no. 4
    
5.
Sharma BS, Sawarkar DP, Suri A. Endoscopic pituitary surgery: Techniques, tips and tricks, nuances, and complication avoidance. Neurol India 2016;64:724-36.  Back to cited text no. 5
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