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Medical and endocrine disease · Core13 / 30
Cushing's disease for transsphenoidal pituitary surgery44-year-old woman, 98 kg, for elective endoscopic transsphenoidal resection of an ACTH-secreting pituitary microadenoma
Pituitary surgery: Cushing physiology, shared airway, diabetes insipidus after resection
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Know this first
Cushing's disease is prothrombotic, so VTE risk is high.
Moon face and buffalo hump predict difficult airway management; obstructive sleep apnoea is common.
Cortisol falls promptly after microadenoma removal: hydrocortisone replacement is needed.
After transsphenoidal surgery, avoid CPAP and forceful mask ventilation: CSF leak and tension pneumocephalus.
The patient
44-year-old woman, 98 kg, for elective endoscopic transsphenoidal resection of an ACTH-secreting pituitary microadenoma.
Cushing's disease: central obesity, moon face, buffalo hump, snoring, easy bruising, osteoporotic vertebral fracture; reflux.
Hypertension and diabetes; on metyrapone, amlodipine and metformin.
Labs: K 3.3 mmol/L, glucose 196 mg/dL. Vitals: BP 162/98, HR 84, SpO2 95% on air, RR 16.
The examiner asks
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Consider
What are your considerations?
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A 44-year-old with Cushing's disease, sleep apnoea, hypertension and diabetes, for elective transsphenoidal resection. Patient
Her cortisol excess touches everything: BP, glucose, weak muscles, thin skin, brittle bones and infection. Disease
Moon face and buffalo hump: a hard mask, possibly a hard intubation, and sleep apnoea. Airway
Her reflux raises her aspiration risk.
Cushing's makes her blood prothrombotic, so her VTE risk is high. Disease
A shared airway, blood in the pharynx and a head-up position. Surgery
Prepare
How do you prepare her?
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Her BP and glucose brought under control, and her potassium of 3.3 corrected. Disease
Metyrapone continued; the steroid plan agreed with endocrinology.
Arterial line before induction, as she's high risk.
Steroids impair her immunity: antibiotic prophylaxis by local protocol.
Careful padding and handling; her skin tears and her bones fracture easily. Surgery
Plan
What is your anaesthetic plan?
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Videolaryngoscope ready; reinforced tube away from the field; throat pack with a removal check. Airway
TIVA with short-acting agents, 20–30° head-up for venous drainage. Surgery
Relaxant titrated to monitoring; steroid excess can potentiate it. Disease
Hydrocortisone 100 mg at induction, 15 mg and 5 mg on day one, cortisol checked on day two.
Awake, sitting extubation; no facemask CPAP afterwards, as it risks CSF leak and pneumocephalus. Airway
Level 2 care: sodium, fluid balance and osmolalities watched for diabetes insipidus. After surgery
Mechanical VTE prophylaxis from theatre; drugs when the neurosurgeon agrees.
Crisis
On day three she suddenly becomes breathless and grey: BP 78/50, HR 128, SpO2 86% on 6 L. Bedside echo shows a dilated right ventricle. What do you do?
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Massive PE until proven otherwise: shock with right-heart strain in a prothrombotic patient. Crisis
Call for help; high-flow oxygen, avoiding mask CPAP or forceful bagging after her skull-base repair.
Support her right ventricle: noradrenaline 0.1–1 mcg/kg/min, with only cautious fluid.
Heparin is the mainstay, but she's 3 days after skull-base surgery: neurosurgery and the PE team decide.
Systemic lysis can save her, but her bleeding risk is high, so catheter-directed or surgical clot removal first.
VA ECMO as a bridge if she keeps deteriorating.
ICU; a caval filter if anticoagulation stays contraindicated. After surgery
Fatal mistakes
No hydrocortisone after the adenoma is removed.
Leaving a prothrombotic Cushing's patient without VTE prophylaxis.
Positive-pressure mask ventilation after skull-base surgery.
Checked against: Anaesthesia for pituitary surgery (2024) · Miller 10e · Stoelting 8e · Barash 9e
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.
Same topic, another patient
Run these after the main case when you have time. Same skills, a different patient or setting.
Another patient · Neuroanaesthesia. Cushing disease for endoscopic transsphenoidal resection. Same pituitary surgery: carotid bleed at the sella, postoperative diabetes insipidus
Know this first
Cushing disease: hypertension, diabetes, OSA, central obesity, fragile skin.
Hydrocortisone at induction, then by protocol with endocrinology.
No nasal CPAP or forceful mask ventilation after surgery: CSF leak, pneumocephalus.
Diabetes insipidus: polyuria with rising serum osmolality, usually 12–48 h after surgery.
Carotid injury: firm packing, resuscitation, then angiography.
The patient
45-year-old woman, 96 kg, BMI 38, for elective endoscopic transsphenoidal resection of an ACTH-secreting pituitary adenoma.
Central obesity, hypertension, insulin-treated type 2 diabetes, and obstructive sleep apnoea on CPAP.
Drugs: amlodipine, metformin, basal insulin.
Vitals: BP 152/94, HR 86, SpO2 95% on air, RR 16; K+ 3.2 mmol/L, glucose 11.4 mmol/L.
The examiner asks
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Consider
What are your concerns?
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A 45-year-old with Cushing disease, for elective endoscopic pituitary resection. Patient
Cushing features: hypertension, diabetes, OSA and central obesity; fragile skin makes cannulation harder. Disease
Her potassium of 3.2 and glucose of 11.4 need correcting first.
Cushing's isn't a difficult airway in itself, but her obesity may make it one. Airway
The carotids run beside the sella; entering that area can cause catastrophic bleeding. Surgery
Prepare
How do you prepare her?
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Steroid plan agreed with endocrinology, e.g. hydrocortisone 100 mg at induction. Disease
Potassium 20 mEq IV over 30 minutes, repeated to normal before surgery; glucose controlled.
Visual fields mapped and documented as a baseline.
Arterial line before induction; she's hypertensive and her nose gets adrenaline.
Crossmatch, wide-bore access, and the team's carotid-injury protocol agreed. Crisis
Level 2 bed for 24 hours because of her OSA. After surgery
Plan
How will you conduct the anaesthetic?
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TIVA with remifentanil; it's titratable and cuts bleeding. Disease
Throat pack to keep blood from her stomach and glottis; out and checked at the end. Airway
Watch for arrhythmias and surges as the nose is infiltrated. Surgery
Co-phenylcaine over adrenaline or cocaine, which can overshoot her BP in Cushing's.
PONV prophylaxis; retching risks bleeding and a CSF leak. After surgery
Extubate awake and sitting up, without coughing; avoid bag-mask ventilation. Airway
No CPAP after; high-flow humidified oxygen by face mask instead. After surgery
Crisis
As the sella is opened, brisk arterial bleeding fills the endoscope view; BP 78/40, HR 128. What do you do?
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Carotid injury until proven otherwise: call for help, massive transfusion protocol. Crisis
Surgeons pack firmly; one suctions while the other controls the bleeding.
Large-bore access; plasma, platelets and red cells 1:1:1, all warmed.
Noradrenaline 0.05–0.3 mcg/kg/min to hold her pressure while blood goes in.
Ionised calcium checked; citrate lowers it.
Once packed and stable, straight to angiography for endovascular repair. After surgery
Crisis
Twelve hours later she is passing 450 mL/h of dilute urine; Na 149 mmol/L. What do you do?
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Diabetes insipidus or a simple diuresis: compare urine and serum osmolality. Crisis
Dilute urine with a high, rising serum osmolality confirms DI.
Each hour: maintenance fluid, and replace two-thirds of what she passed the hour before.
Over 350–400 mL an hour, desmopressin 2–4 mcg SC.
Once awake, drinking to thirst may be enough; sodium checked often. After surgery
Her insulin needs may fall fast after a curative resection; watch her glucose.
Fatal mistakes
No steroid plan agreed with endocrinology.
Nasal CPAP or forceful mask ventilation after surgery.
Missing diabetes insipidus.
Checked against: Miller 10e · Anaesthesia for pituitary surgery (2024) · Anaesthesia and pituitary disease (2011) · Perioperative management of endoscopic transsphenoidal pituitary surgery (2020)