The first concern in endocrine management is to ensure that the hypothalamic-pituitary-adrenal axis is functioning satisfactorily. The easiest way to ensure that sufficient cortisol is present to cover the stress of the operation is to give a bolus of hydrocortisone with induction of anesthesia. Postoperatively, the hydrocortisone can be continued, tapering the replacement level to physiologic replacement levels. Standard replacement is either hydrocortisone 15 mg on rising and 5 mg in the late afternoon or, alternatively, 10 mg on rising, 5 mg at midday, and 5 mg in the late afternoon. Levels should be retested with either a Synacthen test or an insulin stress test at some time after discharge, usually in 2 mo.
Using this regimen, although safe, will be unnecessary in a proportion of patients. In patients with microadenomas, both somatotroph and prolactinomas, replacing cortisol is often unnecessary and it is safe to check a single postoperative 9 am level, and if more than 350 mmol/L (12.8 ^g/dL), the surgeon should have no further concern. This is the policy we have followed for at least our last 500 transsphenoidal patients without problems.
For large tumors, it is safer to rely on some type of replacement. However, if normal cortisol levels existed preoperatively, as they frequently do, postoperative cortisol levels have an 84% chance of being normal as well. Most units would place patients on standard replacement therapy until they can have formal testing of adrenal function (synacthen test or insulin test) in the outpatient department. In some cases, however, a single 9 am cortisol level of >350 mmol/L (12.8 ^g/ dL) following no replacement for >24 h can be considered adequate.
Was this article helpful?
Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...