Hemodynamic response, coughing and the incidence of cerebrospinal fluid leakage on awakening with an endotracheal tube or laryngeal mask airway in place after transsphenoidal pituitary surgery: a randomized clinical trial

Abstract

Background: We aimed to compare systemic and cerebral hemodynamic variables and cough incidence during emergence from general anesthesia after pituitary surgery in patients after extubation of an endotracheal tube (ETT) or after replacing the ETT with a laryngeal mask airway (LMA). Methods: Patients undergoing pituitary surgery were randomized (open-label parallel trial) to awaken with the ETT in place or after it had been replaced with a LMA before extubation. We recorded mean arterial pressure (MAP), heart rate, middle cerebral artery (MCA) flow velocity, regional cerebral oxygen saturation (SrO2), cardiac index, norepinephrine plasma concentrations, need for vasoactive drugs, coughing during emergence, and incidence of postoperative cerebrospinal fluid (CSF) leakage. Results: Forty-five patients were included. MAP was lower during emergence than at baseline in both groups. More patients required antihypertensive drugs in the ETT group (34.8% vs 14.3%; P = 0.17). MCA flow velocity was higher in the ETT group (e.g., mean [95% confidence interval] at 15 min, 103.2 [96.3–110.1] vs 89.6 [82.6–96.5] cm s− 1; P = 0.003). SrO2, cardiac index, and norepinephrine plasma levels were similar. Coughing was more frequent in the ETT group (15% vs 81%; P < 0.001). CSF leakage occurred in 3 patients (13%) in the ETT group only. Conclusions: Placing a LMA before removing an ETT during emergence from anesthesia after pituitary surgery favors a safer cerebral hemodynamic profile and reduced coughing. This strategy may also lower the risk for CSF leakage. Trial registration number: NCT02988804 (clinicaltrials.org) (09/12/2016).