NM-270
Management of Intraoperative Diabetes Insipidus during Resection of a Craniopharyngioma
Antony S, Johnson G
Children's Hospital of Philadelphia, Philadelphia, PA, United states
Summary:
Diabetes insipidus (DI) is a common complication after resection of pituitary tumors. Although DI is more commonly seen postoperatively, DI can manifest during resection even if no symptoms are present preoperatively. Our case describes intraoperative DI that occurred at the onset of tumor resection followed by a lengthy postoperative course of pituitary dysfunction leading to a combination of DI, cerebral salt wasting (CSW), and syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Case History:
Our patient is a previously healthy 21 month female presenting with a 7cm x 5cm x 6cm sellar mass, highly suspicious of a craniopharyngioma. Initial preoperative serum sodium (Na), serum osmolality and urine osmolality levels were within normal limits.
Patient underwent IV induction with propofol, paralytic, and stress dose hydrocortisone. As the surgery progressed, significant polyuria was noted. Na levels and serum osmolality initially remained normal, but we continued monitoring every 30 minutes. The patient’s polyuria continued throughout the case ranging 6-10cc/kg/hr. As the patient’s Na level increased from 134 to 144, we started a vasopressin infusion at 0.5 milliunits per hour and quickly titrated up to 1.5 milliunits per hour.
In the immediate postoperative period, she developed profound hyponatremia with continued polyuria. She appeared volume overloaded with hyponatremia and urine osmolality that was more elevated than would be expected with her degree of hyponatremia. This presentation along with elevated urine Na was suggestive of CSW with a possible SIADH component. The patient’s Na levels fluctuated (120-166) over the next week requiring resumption of the vasopressin infusion and eventual transition to oral DDAVP.
Discussion:
The endocrine disturbances associated with pituitary tumors can be complex. Because DI is usually a transient phenomenon following surgery, patients can maintain neutral fluid balance by drinking to satiety and discharged by postop day 2-3 (1). This can be challenging in the pediatric population. Our patient’s thirst drive was compromised, making it difficult to maintain a neutral fluid balance. This patient’s trend of DI followed by hyponatremia may be from a triphasic pattern of endogenous vasopressin secretion. The initial phase of symptomatic DI typically occurs 24 hours after surgery although seen intraop here, which is rare. A second phase of inappropriate vasopressin secretion can occur potentially causing hyponatremia. There is then a third phase with a return to DI occurring up to 2 weeks after initial resection. This third phase can be complicated by CSW and thirst disorders (2). We hope increased awareness of this triphasic response can help guide perioperative management to avoid severe life threatening electrolyte disturbances.
References:
1. Zada G, Woodmansee WW, Luliano S, Laws ER. Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery. Asian Journal of Neurosurgery. 2010; 5(1):1-6.
2. Ghiarardello S, Hopper N, Albanese A, Maghnie M. Diabetes insipidus in craniopharyngioma: Postoperative management of water and electrolyte disorders. J Pediatr Endocrinol Metab. 2006; 19:413–21.
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