Perioperative Management of a Patient With Cushing Disease

Abstract

Patients with Cushing’s disease (CD) may present with both chronic and acute perioperative complications that necessitate multidisciplinary care. This review highlights several objectives for these patients before and after transsphenoidal surgery. Preoperative management includes treatment of electrolyte disturbances, cardiovascular comorbidities, prediabetes/diabetes, as well as prophylactic consideration(s) for thromboembolism and infection(s). Preoperative medical therapy (PMT) could prove beneficial in patients with severe hypercortisolism or in cases of delayed surgery. Some centers use PMT routinely, although the clinical benefit for all patients is controversial. In this setting, steroidogenesis inhibitors are preferred because of rapid and potent inhibition of cortisol secretion. If glucocorticoids are not used perioperatively, an immediate remission assessment postoperatively is possible. However, perioperative glucocorticoid replacement is sometimes necessary for clinically unstable or medically pretreated patients and for those patients with surgical complications. A nadir serum cortisol < 2-5µg/dl during 24-74 hours postoperatively is generally accepted as remission; higher values suggest non-remission, while a few patients may display delayed remission. If remission is not achieved, additional treatments are pursued. The early postoperative period necessitates multidisciplinary awareness for early diagnosis of adrenal insufficiency (AI) to avoid adrenal crisis, which may be also potentiated by acute postoperative complications. Preferred glucocorticoid replacement is hydrocortisone, if available. Assessment of recovery from postoperative AI should be undertaken periodically. Other postoperative targets include decreasing antihypertensive/diabetic therapy if in remission, thromboprophylaxis, infection prevention/treatment, and management of electrolyte disturbances and/or potential pituitary deficiencies. Evaluation of recovery of thyroid, gonadal and growth hormone deficiencies should be also performed in the following months postoperatively.

Multiple Deep Vein Thromboses After Curative Surgery for Cushing Disease: A Case Presentation and Review

“…There may, however, be a shift toward greater recognition of thrombotic risk in Cushing's disease. 8,9 In a recent Pituitary Society statement, prophylactic anticoagulation was recommended for individuals with a history of embolism, abnormal coagulation studies, severe hypercortisolism, current use of estrogen or OCP, poor mobility, extended hospital stay, high postoperative cortisol concentration or cortisol overreplacement. 9 In addition, in a recent review, Varmalov et al recommend thromboprophylaxis for 2-6 weeks postoperatively in Cushing's patient, with regimens of 2-3 months for patients with J o u r n a l P r e -p r o o f 6 highest thrombotic risk.…”

“…9 In addition, in a recent review, Varmalov et al recommend thromboprophylaxis for 2-6 weeks postoperatively in Cushing's patient, with regimens of 2-3 months for patients with J o u r n a l P r e -p r o o f 6 highest thrombotic risk. 8 However, identifying the highest risk patients remains a challenge, and practice patterns still vary significantly among pituitary experts who report prescribing anticoagulation after surgery for anywhere from 1-2 days of the hospital stay up to 2-3 months. 9 The risk of thrombotic events in patients with CS has been reported to be up to 10-18x higher than the general population.…”

“…However, there may be a shift toward greater recognition of thrombotic risk in patients with CD. 8 , 9 In a recent statement by the Pituitary Society, prophylactic anticoagulation was recommended for individuals with a history of embolism, abnormal coagulation test results, severe hypercortisolism, poor mobility, extended hospital stay, high postoperative cortisol concentrations, or cortisol overreplacement and for those currently using estrogen or oral contraceptive pills. 9 In addition, in a recent review, Varlamov et al 8 recommended thromboprophylaxis for 2 to 6 weeks before surgery in patients with CD, with regimens of 2 to 3 months for patients with the highest thrombotic risk.…”

Glucocorticoid Withdrawal Syndrome following treatment of endogenous Cushing Syndrome

“…A standard protocol includes securing serum electrolytes and cortisol, plasma ACTH, capillary blood glucose, blood pressure, and urine specific gravity every 6 h for 24–48 h while withholding all glucocorticoids. Consecutive serum cortisol values less than 2–5 µg/dL (we use < 3 µg/dL) are sufficient to document successful tumor resection and to begin glucocorticoid therapy[ 35 ]. Post-operative signs and symptoms of AI including vomiting, hyponatremia, hypoglycemia, and hypotension should also mandate immediate glucocorticoid support.…”

“…By comparison, post-BLA patients receiving supraphysiologic hydrocortisone doses usually do not need mineralocorticoid support until their dose is tapered to near physiologic replacement. In the acute postoperative period, several medical comorbidities accompanying CS may reverse rapidly and require medication adjustments[ 35 ]. In particular, insulin and oral hypoglycemic drugs, potassium-sparing diuretics such as spironolactone, and other cardiovascular drugs are typically tapered or discontinued as glucose counter-regulation and electrolyte balance change rapidly upon cortisol reduction.…”