Symptoms of secondary adrenal insufficiency in pituitary patients may be subtle, and the best way to guard against perioperative adrenal insufficiency is to give prophylactic hydrocortisone cover to all patients. This is a safe policy, but in selective adenomectomy hydrocortisone is unnecessary so long as the HPA axis is normal. Hout et al. studied 82 patients with microadenomectomy with a normal HPA axis (2). Only two patients showed evidence of HPA insufficiency in the postoperative period, in whom it was clinically evident and replacement was given safely. Our policy is to administer 100 mg of hydrocortisone on induction only to patients with evidence of cortisol insufficiency.
During transsphenoidal surgery, the operative field is exposed to commensals present in the sphenoid sinus and the operation is therefore contaminated. Despite this, and probably because of the extra-arachnoid nature of most transsphenoidal surgery, the infection rate after surgery is low. We use antibiotic prophylaxis in the form of a single dose of 1.5 g cefuroxime iv on induction, although some surgeons consider this unnecessary.
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