- Department of Neurosurgery, PGIMER, Chandigarh, India,
- Department of Endocrinology, PGIMER, Chandigarh, India,
- Department of Pharmacology, PGIMER, Chandigarh, India,
- Department of Anaesthesia, PGIMER, Chandigarh, India,
- Barbra Davis Center for Diabetes, Aurora, Co, USA
Department of Endocrinology, PGIMER, Chandigarh, India,
DOI:10.4103/2152-7806.136399Copyright: © 2014 Mukherjee KK This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Mukherjee KK, Dutta P, Singh A, Gupta P, Srinivasan A, Bhagat H, Mathuriya SN, Shah VN, Bhansali A. Choice of fluid therapy in patients of craniopharyngioma in the perioperative period: A hospital-based preliminary study. Surg Neurol Int 08-Jul-2014;5:105
How to cite this URL: Mukherjee KK, Dutta P, Singh A, Gupta P, Srinivasan A, Bhagat H, Mathuriya SN, Shah VN, Bhansali A. Choice of fluid therapy in patients of craniopharyngioma in the perioperative period: A hospital-based preliminary study. Surg Neurol Int 08-Jul-2014;5:105. Available from: http://sni.wpengine.com/surgicalint_articles/choice-of-fluid-therapy-in-patients-of-craniopharyngioma-in-the-perioperative-period-a-hospital-based-preliminary-study/
Background:Electrolyte imbalance and acute diabetes insipidus (DI) are the most common complications in patients undergoing craniopharyngioma surgery. Improper management of water and electrolyte imbalance is common cause of morbidity and mortality. Data is sparse and controversial regarding the choice of fluid therapy in this population during perioperative period.
Methods:In this retrospective-prospective study involving 73 patients (58 retrospective), the type of fluid therapy was correlated with occurrence of hypernatremia, hyponatremia, DI, morbidity, and mortality. In the retrospective study, 48 patients received normal saline and 10 received mixed fluids as per the prevailing practice. In the prospective group, five patients each received normal saline, half normal saline, and 5% dextrose randomly.
Results:The sodium values were significantly higher in first 48 h in the group that received normal saline compared with other groups (P P = 0.05), while the group that received 5% dextrose was associated with hyponatremia, hypoglycemia, and seizures. There was no perioperative hypotension with use of any of the fluids.
Conclusion:Our results indicate half normal saline was fluid of choice with diminished incidence of water and electrolyte abnormalities without increase in mortality during postoperative period.
Keywords: Craniopharyngioma, diabetes insipidus, hypernatremia, half normal saline
Craniopharyngiomas are sellar and/or suprasellar and locally invasive tumors compressing critical neural and vascular structures. Surgery for these tumors may be challenging given the significant potential for harms with any intervention involving these critical structures and young age at presentation.[
In the postneurosurgical settings, the differentiation of central DI from polyuria as a result of diuresis due to intraoperative fluid administration is important.[
Careful history of perioperative fluid intake and output, laboratory investigations such as urine specific gravity, urine and serum osmolality and serum electrolytes are required to make correct diagnosis of DI. In settings of DI and polyuria due to excessive administration of isotonic fluid, hypernatremia (serum sodium ≥150 mmol/L) is usually observed. This poses potential risk of serum hyperosmolality and if uncorrected, may lead to serious complications like stupor, seizures, renal failure, and very high values can potentially be fatal.[
The study by Shucart and colleagues showed that dextrose in water solution for an intravenous fluid or tap water for oral administration was better for the management of DI in neurosurgical setting.[
The study was an analytical prospective and retrospective, conducted on patients of histo-pathologically verified craniopharyngiomas in different age groups at Postgraduate Institute of Medical Education and Research, Chandigarh, India, a leading tertiary care institute in north India. The patients for prospective study were recruited from January 2012 to January 2013 and the retrospective study patients underwent surgery between January 2002 and January 2010. The surgeries were performed by a single neurosurgeon (KKM) by transcranial route. Patients in whom transsphenoidal surgery was performed were excluded from the study. All patients were managed in the postoperative setting by specialist intensivist (HB). Written informed consent was taken from all the patients and the study was approved by Institute's Ethics Committee. The patients in the prospective group were allotted randomly from computer generated random numbers to receive different types of fluids. They were divided into three subgroups (five in each) according to the type of fluids infused during intraoperative period. In the retrospective group, the type of fluid was analyzed from hospital records. Patients were deemed to receive fluid boluses for hypotension in the perioperative period. The exclusion criteria were mere biopsy, ventriculoperitoneal (VP) shunt or only reservoir placement in tumor, patients having diabetes mellitus, or known DI.
All patients were evaluated by computerized tomography (CT) scan and contrast enhanced magnetic resonance imaging (CEMRI) of hypothalamo-pituitary area. Preoperative serum and urinary sodium levels, serum and urine osmolality, urine specific gravity, history suggestive of preoperative DI, fasting plasma glucose, Glasgow coma scale (GCS), visual acuity and field, neurological deficits, and hormonal parameters were recorded. If patients were deficient of pituitary hormones, they were replaced adequately for at least one month before taking decision for surgery.
The intraoperative evaluations included extent of excision of tumor, type of fluid used for first 7 days following craniopharyngioma surgery, total amount of fluid given, intraoperative intake/output and central venous pressure (if applicable).
Postoperative evaluation (daily till the end of first week or normalization of patient's clinical and biochemical parameters) included serum and urine sodium, serum and urine osmolality, urine specific gravity, incidence of DI, SIADH, serum sodium, use and dose of desmopressin administered, plasma glucose, postoperative GCS, vision, neurological deficits and serum thyroxine and serum cortisol Postoperative DI was managed with desmopressin subcutaneously at an initial dose of 5 μg when urine output was 200-250 ml/h for ≥2 h with urine specific gravity <1.005 or urine osmolality <200 mosm/kg of water as per standard protocol.[
The urinary and serum osmolality were measured by principle of freezing point depression method (Fiske® 210 Micro-Sample Osmometer, USA). All the hormonal parameters were done by immunochemiluminiscence method (COBAS 6001, Roche Diagnostic, Germany). Serum and urine sodium were measured by immunochemiluminiscence method (ELCYS 2010, Roche Diagnostic, Germany)
The sample size of 5 per group was required to detect a difference of 10 mmol/L in serum sodium value with variance of 25. The alpha was set to 0.05 and adjusted for Bonferroni corrections for multiple comparisons. The power was set to 80%. Continuous data was expressed as mean (standard deviation). Categorical data was expressed as numbers or percentage. Parametric data was compared using analysis of variance and nonparametric data was done using Chi-square test. A P value less than 0.05 was considered as significant. Repeated measure data was analyzed with repeated measures of analysis of variance (ANOVA) (Friedman's test for nonparametric data) with Bonferroni correction for comparison between groups. Proportional data was analyzed with Z test. Correlation of data was analyzed by Pearson's or Spearman's correlation based on the distribution of data.
The study included a total of 77 patients (58 in retrospective group, male: female 40:18) and 19 in the prospective group. Seventy-three patients were available for final analysis (15 in the prospective group, male: female 6:9). The concert of flow of patients is shown in
In the prospective group, young children (7, 47% were less than 20 years of age) were the most commonly affected by the disease. There was no significant difference in the age between the subgroups receiving different category of intravenous fluids. Loss of vision was the most common preoperative complaint of the patients, followed by headache and vomiting. The visual acuity and field defect was significant among all the patients ranging from mild field defect to total absence of vision. Short stature was present in 13 (90%) children, hypothyroidism in 2 (13.7%), and hypocortisolism in 6 (40%). Only one patient (5%) out of the total number of patients in the prospective group had preoperative DI and was excluded from the final analysis. Fifteen patients had sellar and suprasellar components and 4 had only sellar component, 13 had mixed solid and cystic components and 5 had calcification [
There was one death observed in the prospective group following left hemispheric infarct on second postoperative day with sodium levels at the time of deterioration approaching 160 meq/l. He also had associated DI. There was no evidence of intraoperative vascular insult, hypoxia, or any other known aggravating factors in this patient. The trend of sodium values, occurrence of hypernatremia, DI in three subgroups are depicted in Tables
The clinical presentation and radiological finding were comparable to the prospective group [
There was no significant difference in serum sodium in patients receiving NS and the fluid-mix (P = 0.60). There were six deaths and all of them had received NS in their perioperative period. All of them had hypernatremia (serum sodium ≥150 mEq/L) in the immediate postoperative period and before deterioration. The patients died primarily due to cerebral infarcts at various locations, which were attributed to hypernatremia. The tumor volume and extent was comparable both in pediatric and adult patients (46 vs 42.4 cm3, P = 0.67).
Both in retrospective and prospective groups (multivariate analysis), even though there were deaths observed in NS groups, the sample size was not sufficiently powered to detect a significant difference in mortality between the groups but on univariate analysis, the portion of deaths in NS group (retrospective group) was significantly more than the mixed fluid groups (P = 0.02).
Use of NS as an infusible in perioperative period has high risk of hypernatremia and DI, 5% dextrose has hyperglycemia and hyponatremia. The use of N/2 saline is associated with lower risk of fluctuating serum sodium and hyernatremia. Therefore, it is favorable to use half NS as the sole intraoperative fluid in patients undergoing craniopharyngioma surgery. All deaths happened in patients receiving NS.
In the present study, in the prospective group, prevalence of hypernatremia in the patients who received NS was 100%. In the other two groups, it was zero. Two patients (40%) who received 5% dextrose developed hyponatremia. The incidence of sodium disturbance was reported between 12% and 76% in previous studies.[
In the prospective study, preoperative central DI was present in only one patient (5%) but present in all patients in the peri- and immediate postoperative period. In the retrospective group, 80% had DI in the perioperative period. The classical textbook triphasic pattern of endogenous vasopressin secretion was uncommon (10%). Overzealous glucocorticoid and phenytoin therapy complicates the risk of life threatening hyper or hypo natremia and DI.[
In the prospective study, there was significant hypernatremia in all patients in whom NS was used as a sole intraoperative fluid as compared with N/2 saline or 5% dextrose in first 48 h of postoperative period. There was no significant difference in biochemical or hormonal profile of patients who received either of N/2 saline or 5% dextrose during this time frame. Being hypotonic these later two fluids theoretically pose increased chances of cerebral edema but no such thing was observed in our study. The other fear was that of hyperglycemic during surgery with 5% dextrose. Use of dextrose is also associated with higher risk of ischemia therefore it is not a preferred intraoperative fluid in cranial surgery. As stated earlier, hyperglycemia was observed in two patients who received 5% dextrose requiring insulin for a short period of time. It did not pose any problem in patient's recovery from general anesthesia. Their hemoglobin A1c values were in the nondiabetic range. The same two patients had hyponatremia, which is comparable to the incidence in identical circumstances.[
In our retrospective study, NS had been the choice of intraoperative fluid, irrespective of the postoperative sodium values. We tried to analyze the patient outcome in relation to serum sodium values with the intraoperative type of fluids, particularly in the first 48 h, since a lot of other factors come into play later. Approximately 80% of patients had significant hypernatremia in the immediate postoperative period. Patients (20%) who did not have hypernatremia but DI, nearly half of them were found to be hypo cortisolic. This is due to masking of hypernatremia in presence of hypocortisolism.[
All deaths in retrospective group happened in patients who received NS as the sole fluid in the perioperative period. They had significant hypernatremia particularly at the time of deterioration with average serum sodium value of 160mmol/L. The possible causes of death in these patients was due to acute cerebral infarcts at various sites with variable severity, directly correlating to hypernatremia as all other predisposing factors for infarcts were absent.
Among the immediate causes of morbidity and mortality, DI, and hypernatremia pose a significant effect on outcome of patients undergoing craniopharyngioma surgery.[
In normal physiology daily salt intake varies from 50 to 90 mmol as sodium chloride. Water and sodium homeostasis is maintained primarily by kidneys and skin under conditions of reduced salt intake or excessive extra renal losses. The normal kidneys can reduce sodium excretion to less than 1 mmol/day in acute stressful condition. Postoperatives state is a condition of reduced salt intake and apparent mineralo-corticoid excess. The increased excretion of aldosterone is influenced by reduced extracellular volume, low sodium diet, and excessive potassium administration. Such kind of mechanisms work under the normal hypothalamo-pituitary axis.[
The clinical presentation and radiological findings in our studies were comparable to historical data by various authors.[
The strength of this study is that this is a randomized controlled trial. Equal number of patients in either group had similar size and type of tumor (sellar/suprasellar) and all were operated by transcranial route, as the location of the tumor and damage to hypothalamus will have a profoundly different impact on postoperative serum sodium. Similarly, comparable number of patients received fluid boluses and the amount of fluid was also not different. Therefore, the occurrence of mortality, DI, and hypernatremia is unlikely to be influenced by this. The limitations of this study are that this was a heterogeneous study design (retrospective and prospective), small number of subjects as a whole in the prospective group and in the subgroups, absence of blinding, and lack of autopsy in patients who died of cerebral infarcts. Since the study has involved the measurement of objective parameters mostly absence of blinding would not have biased the results.
The type of intraoperative fluid should be given utmost importance while planning craniopharyngioma surgery. Use of NS promotes occurrence of hypernatremia, DI, and mortality, while 5% dextrose promotes hyponatremia hyperglycemia and seizures. This study results indicate half NS as the fluid of choice with diminished incidence of water and electrolyte abnormalities without increase in mortality during postoperative period. In future, a large prospective blinded study is required to determine the consistency of our results and make more clear recommendations.
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