Category: Pituitary Disorders/Neuroendocrinology

Monitor: 11

11 - APPROPRIATE LABORATORY EVALUATION IN POST-PITUITARY SURGERY PATIENTS

Saturday, Apr 27
11:30 AM – 12:00 PM

Objective :

Pituitary hormone deficiencies in post pituitary surgery patients are very common, especially Diabetes Insipidus and secondary adrenal insufficiency.  There are several strategies to evaluate hypothalamic-pituitary-adrenal axis, typically with 8 AM cortisol on the 1st or 2nd postoperative day (POD), at least 24 hours after the last dose of hydrocortisone. Secondary hypothyroidism and post-operative SIADH are not apparent until several days later. There is no support in literature for post-operative testing of other pituitary hormones such as growth hormone, prolactin, FSH and LH. Inappropriate lab evaluation not only leads to unnecessary cost but also gives a false sense of alarm or reassurance. We evaluate the pattern of labs ordered and determine if these are consistent with current recommendation.


Methods :

This is a retrospective, single-center cohort study done at University of Kansas Medical Center. The study population includes adult patients between ages 18-99 years who underwent endoscopic transphenoidal pituitary surgery between January 1, 2016 to December 31, 2016. We identified 20 patients through HERON data base.


Results :

13 out of 20 patients (65%) had non-functioning pituitary adenoma.  4 patients (30%) had secondary adrenal insufficiency and were treated with glucocorticoids prior to surgery. 3 patients without previous diagnosis of secondary adrenal insufficiency also received peri-operative stress dose steroids. 18 out of 20 patients had POD 1 AM cortisol drawn. Out of these, 5 (27%) patients had peri-operative stress dose steroids, thus rendering cortisol value invalid. 4 out of 18 (22%) patients who had POD 1 cortisol drawn had Cushing’s disease and thus post-operative cortisol check was helpful. Cortisol check was also appropriate in the remaining 9 patients (50%). 18 out of 20 patients had POD 1 prolactin checked, out of which 5 (27%) patients had prolactinoma, while it was not useful for the remaining 13 (72%) patients. 17 out of 20 (85%) and 16 out of 20 (80%) patients had POD 1 IGF-1 and growth hormone checked respectively. None of these patients had acromegaly, therefore, not useful. 19 out of 20 patients had post-operative free T4 checked, out of which 4 patients had pre-operative secondary hypothyroidism. 18 out of 20 (90%) patients had post-operative TSH checked, which was not useful.


Discussion : Our results showed that there is a gap between present practice at our institution and current recommendation. Up to 90% of pituitary surgery patients had unnecessary labs drawn.


Conclusion :

We strongly believe that there is a need for an update order set to appropriately evaluate for post-operative pituitary hormone deficiencies among these patients.

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Neha H. Lalani

Fellow
University of Kansas Medical Center
Chester, Virginia

Graduated from University of Kansas Medical Center in June 2018. Currently practicing in Petersburg, VA.

Tarandeep Kaur

Fellow
University of Kansas Medical Center

Graduated from University of Kansas Medical Center in June 2018. Currently practicing in Stockton, CA.

Rudruidee Karnchanasorn

Assistant Professor
University of Kansas Medical Center

Assistant professor at University of Kansas Medical Center.