Category: Pituitary Disorders/Neuroendocrinology

Monitor: 4

4 - AN EFFECTIVE AND PRACTICAL FLUID RESTRICTION PROTOCOL TO ELIMINATE HYPONATREMIA AND READMISSIONS AFTER TRANSSPHENOIDAL RESECTION

Friday, Apr 26
11:30 AM – 12:00 PM

Objective :

Delayed hyponatremia following transsphenoidal resection (TSR) of pituitary lesions affects between 4-20% of surgical cases and is the primary cause for hospital readmissions (56% of cases) and post-operative morbidity. Hyponatremia after TSR is delayed and usually occurs around post operative days (POD) 6-7 (range 3-12). Without preceding diabetes insipidus (DI), there are no reliable risk factors, leading to challenges in the detection and timely management of this complication.


Methods :

We implemented fluid restriction from POD4 through 8 following TSR in consecutive patients undergoing surgery at a Pituitary Center. We included all patients undergoing TSR or biopsy of pituitary lesions except if they had manifested DI requiring more than 1 dose of desmopressin post-operatively.


 


Results :

From our Pituitary Center database, the rate of hyponatremia from mid 2016 to early 2018 was 14.5%, with 50% of those patients requiring readmission with a total of 12 ICU days and a mean sodium level (Na) of 114.8 mEq/L (range 103-121). 50% of patients were managed with fluid restriction at home with a mean sodium of 130.5 mEq/L (range 129-132). After implementation of 1250cc fluid restriction, 2 of 7 patients developed hyponatremia with Na levels of 116 and 132 mEq/L. Further restriction of fluid intake to 1000 cc lead to zero cases of hyponatremia in 44 patients studied prospectively. Average sodium was 142.4 mEq/L (range 137-148) and there was no evidence of dehydration. Furthermore, all patients were able to adhere to the protocol and there were no adverse outcomes.


Discussion :

Delayed hyponatremia is an unfortunate and unpredictable complication following TSR, thought to be due to delayed and unregulated release of vasopressin combined with excessive water intake due to dry mouth from the surgery. It leads to significant morbidity and healthcare costs from readmission and emergency room visits. Without preceding DI, it is difficult to predict who is at greatest risk. The optimal approach lies in the prevention, rather than treatment, of this complication. With pre-emptive implementation of a practical fluid restriction protocol, we have been able to eliminate delayed hyponatremia in 100% of our patients. Furthermore, given the short nature of intervention, only on POD 4-8 when patients are at greatest risk, this protocol is simple for patients to follow but still allows for fluid intake in the early days post-operatively when patients have the most thirst.


Conclusion :

The restriction of fluids to 1L on POD 4 to 8 after TSR is a successful strategy to  prevent delayed hyponatremia and decrease morbidity and healthcare costs.


 

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Dina Winograd

Clinical Fellow
Baylor College of Medicine
Houston, Texas

Clinical Endocrinology fellow at Baylor College of Medicine

Sherly Sebastian

Assistant Professor of Neurosurgery
Baylor College of Medicine, Pituitary Center at Baylor St. Luke's Medical Center

Pituitary Center Nurse Practitioner

Mas Takashima

Associate Professor of Otolaryngology
Baylor College of Medicine, Pituitary Center at Baylor St. Luke's Medical Center
Houston, Texas

Associate Professor of Otolaryngology

Daniel Yoshor

Professor and Chairman of Neurosurgery
Baylor College of Medicine, Pituitary Center at Baylor St. Luke's Medical Center

Professor and Chair, Marc J. Shapiro Endowed Chair of Neurosurgery

Susan L. Samson

Associate Professor of Medicine and Neurosurgery
Baylor College of Medicine, Baylor St. Luke's Medical Center
Houston, Texas

Medical Director of the Pituitary Center at Baylor St Luke's Medical Center, Houston TX.

Kristen Staggers

Dina Winograd

Clinical Fellow
Baylor College of Medicine
Houston, Texas

Clinical Endocrinology fellow at Baylor College of Medicine