30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients

Ghiam, Michael K.; Chyou, Darius; Dable, Cortney; Katz, Andrew P.; Eichberg, Daniel G.; Zhang, Hang; Ayala, Alejandro; Kargi, Atil Y.; Komotar, Ricardo J.; Sargi, Zoukaa

doi:10.1055/s-0041-1729980

Cited by 5 publications

(15 citation statements)

References 41 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Posterior pituitary manipulation can disturb water balance and result in serum sodium alterations, including transient or permanent central diabetes insipidus, and in rare cases the triphasic response of diabetes insipidus, followed by syndrome of inappropriate secretion of antidiuretic hormone (SIADH), and finally permanent diabetes insipidus[ 41 , 42 ]. In the first week or two after discharge, the most common cause for readmission is hyponatremia[ 43 , 44 ], although the mechanisms responsible for this transient SIADH state are not known. For this reason, patients should be instructed to drink only when thirsty and not as an alternative to solid foods or for social reasons for 7–10 days after the surgery.…”

Section: Acute Care: Perioperative Planning Coaching and Managementmentioning

confidence: 99%

Glucocorticoid Withdrawal Syndrome following treatment of endogenous Cushing Syndrome

Findling

Auchus

2022

Pituitary

View full text Add to dashboard Cite

Purpose: Literature regarding endogenous Cushing syndrome (CS) largely focuses on the challenges of diagnosis, subtyping, and treatment. The enigmatic phenomenon of glucocorticoid withdrawal syndrome (GWS), due to rapid reduction in cortisol exposure following treatment of CS, is less commonly discussed but also difficult to manage. We highlight the clinical approach to navigating patients from GWS and adrenal insufficiency to full hypothalamic-pituitary-adrenal (HPA) axis recovery. Methods: We review the literature on the pathogenesis of GWS and its clinical presentation. We provide strategies for glucocorticoid dosing and tapering, HPA axis testing, as well as pharmacotherapy and ancillary treatments for GWS symptom management. Results: GWS can be difficult to differentiate from adrenal insufficiency and CS recurrence, which complicates glucocorticoid dosing and tapering regimens. Monitoring for HPA axis recovery requires both clinical and biochemical assessments. The most important intervention is reassurance to patients that GWS symptoms portend a favorable prognosis of sustained remission from CS, and GWS typically resolves as the HPA axis recovers. GWS also occurs during medical management of CS, and gradual dose titration based primarily on symptoms is essential to maintain adherence and to eventually achieve disease control. Myopathy and neurocognitive dysfunction can be chronic complications of CS that do not completely recover. Conclusions: Due to limited data, no guidelines have been developed for management of GWS. Nevertheless, this article provides overarching themes derived from published literature plus expert opinion and experience. Future studies are needed to better understand the pathophysiology of GWS to guide more targeted and optimal treatments.

show abstract

Section: Acute Care: Perioperative Planning Coaching and Managementmentioning

confidence: 99%

Glucocorticoid Withdrawal Syndrome following treatment of endogenous Cushing Syndrome

Findling

Auchus

2022

Pituitary

View full text Add to dashboard Cite

show abstract

“…8,9 Thirty-day unplanned readmission rates for ETPS are reported to range from 4.6% to 13.9%. 6,[10][11][12][13][14][15][16][17][18] . Delayed hyponatremia is common following ETPS which can occur in up to 25% of patients, with more severe or symptomatic cases requiring readmission in up to 7.6% of patients.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

“…We identified post-discharge coordination with endocrinologist the only statistically significant protective factor for all cause readmissions. 18…”

Section: Accepted Manuscriptmentioning

confidence: 99%

“…8,9 Thirty-day unplanned readmission rates for ETPS are reported to range from 4.6 to 13.9%. 6,[10][11][12][13][14][15][16][17][18] Delayed hyponatremia is common following ETPS which can occur in up to 25% of patients, with more severe or symptomatic cases requiring readmission in up to 7.6% of patients. 6,11,17,[19][20][21] The pathophysiology is consistent with the triphasic pituitary response characterized by early hypernatremia (diabetes insipidus [DI]), followed by delayed vasopressin release with hyponatremia, and finally, delayed hypernatremia from depleted vasopressin stores.…”

Section: Introductionmentioning

confidence: 99%

“…22 Readmission from delayed hyponatremia usually occurs on postoperative days (PODs) 5 to 7 which coincides with a nadir in serum sodium. 18,22 Although prior studies have linked white race, female sex, tumor size, preoperative hypopituitarism, and postoperative DI to delayed hyponatremia, there is no consensus agreement on reliable risk factors. Identification of patients at risk for delayed hyponatremia remains elusive.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care

Ghiam

Ali

Dable

et al. 2022

J Neurol Surg B Skull Base

Self Cite

View full text Add to dashboard Cite

Background: Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors prior retrospective review identified endocrinology follow up as protective factor. Objectives: Implementation of a multidisciplinary post-operative care pathway (POC pathway): (a) to reduce 30-day hospital readmissions following ETSP; (b) improve inpatient and outpatient coordination of care with endocrinologist. Methods: Single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized post-discharge 1-1.5L/day fluid restriction, a post-operative day 5-7 serum sodium, and endocrinology follow up within 1 week of discharge to stratify patients into tiered hyponatremia regimens. Results: 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All cause readmission was significantly reduced following implementation of the POC pathway (14% vs 6%, p=0.015). Coordination with endocrinologist significantly increased in the inpatient (96% vs. 83%, p <0.001)) and outpatient (77% vs. 68%, p=0.042) setting. Patients who were not in the POC pathway had the highest risk of readmission (OR: 2.5; 95% CI: 1.1-5.5). Conclusions: A multidisciplinary POC pathway incorporating endocrinologist in conjunction with post-discharge weight-based fluid restriction and post-operative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

show abstract

Emergency department visits following endoscopic skull base surgery: An opportunity for improvement

Godse

Jarmula

Kshettry

et al. 2023

Int Forum Allergy Rhinol

View full text Add to dashboard Cite

BackgroundReadmissions are major healthcare expenditures, key hospital metrics, and are often preceded by an evaluation in the emergency department (ED). The purpose of this study was to analyze ED visits within 30 days of endoscopic skull base surgery (ESBS), risk factors for readmission once in the ED, and ED‐related evaluation and outcomes.MethodsRetrospective review from January 2017 to December 2022 at a high‐volume center of all ESBS patients who presented to the ED within 30 days of surgery.ResultsOf 593 ESBS cases, 104 patients (17.5%) presented to the ED following surgery within 30 days, with a median presentation of 6 days post‐discharge (IQR 5–14); 54 (51.9%) patients were discharged while 50 (48.1%) were readmitted. Readmitted patients were significantly older than discharged patients (median 60 years, IQR 50–68 vs. 48 years, 33–56; p < 0.01). Extent of ESBS was not associated with readmission or discharge from the ED. The most common discharge diagnoses were headache (n = 13, 24.1%) and epistaxis (n = 10, 18.5%); the most common readmitting diagnoses were serum abnormality (n = 15, 30.0%) and altered mental status (n = 5, 10.0%). Readmitted patients underwent significantly more laboratory testing than discharged patients (median 6, IQR 3–9 vs. 4, 1–6; p < 0.01).ConclusionsApproximately half of patients who presented to the ED following ESBS were discharged home but underwent significant workup. Follow‐up within 7 days of discharge, risk‐stratified endocrine care pathways, and efforts to address the social determinants of health may be considered to optimize postoperative ESBS care.

show abstract

30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients

Cited by 5 publications

References 41 publications

Glucocorticoid Withdrawal Syndrome following treatment of endogenous Cushing Syndrome

Glucocorticoid Withdrawal Syndrome following treatment of endogenous Cushing Syndrome

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care

Emergency department visits following endoscopic skull base surgery: An opportunity for improvement

Contact Info

Product

Resources

About