DP36: ANESTHETIC CONSIDERATIONS AND PERIOPERATIVE MANAGEMENT OF A PATIENT WITH A SUPRASELLAR ASTROCYTOMA AND HISTORY OF DIENCEPHALIC SYNDROME
Patricia Uher, MD1; Jenna Hart, DO1; Ellise Cappuccio, MD2; Hannah Tuckwell, MD2
1Jackson Memorial Hospital; 2Nicklaus Children's Hospital
Introduction/Background: Diencephalic syndrome (DS) is a rare cause of failure to thrive in young children that presents with severe cachexia despite maintenance of linear growth and visual field defects caused by a tumor in the hypothalamic-optic chiasmatic region. Surgical intervention for suprasellar tumors presents a challenge for anesthesiologists due to the patient’s cachectic body habitus, dehydrated fluid status, electrolyte and hormone imbalances, and potential intracranial pressure changes. The authors here describe the perioperative anesthetic considerations and management of an 11-year-old, 30.5 kg male scheduled for a stereotactic tumor biopsy and a left-sided, endoscopic-assisted placement of an Ommaya reservoir for a hypothalamic chiasmatic low-grade astrocytoma. The consent from the patient’s parents to present this case is available upon request.
Methods: In the preoperative assessment, laboratory values (particularly hypothalamic hormones), medication supplementation, and brain MRI (Figure 1) were reviewed. On preoperative physical examination, the patient was verbal, moved all four extremities, and had no vision in the left eye; the airway examination was unremarkable. Subsequently, the patient was transported to the MRI suite for the stereotactic biopsy and reservoir placement.
Anesthesia was induced via mask ventilation with 8% sevoflurane. Following the placement of two peripheral intravenous lines and administration of intravenous rocuronium, the patient’s airway was secured with a cuffed endotracheal tube and a urinary catheter was placed. The patient was adequately warmed throughout the procedure with heating pads and forced air warming blankets. Intravenous lines and bony prominences were carefully padded to prevent pressure injury. Post-induction, due to low preoperative cortisol levels (1.2 µg/dL), 8 mg of intravenous dexamethasone was administered. Anesthesia was maintained with a combination of volatile anesthetic (sevoflurane) and intravenous anesthetic (propofol, remifentanil, dexmedetomidine). Following successful stereotactic biopsy and reservoir placement, the patient was extubated awake outside of the MRI suite.
Results: The total duration of anesthesia was six hours, and intraoperative blood loss was minimal. The patient was transported to the post-anesthesia care unit for recovery. On postoperative day 1, the patient was discharged home in stable condition with outpatient endocrinology and neurosurgical follow-up.
Discussion/Conclusion: Most of the literature on diencephalic syndrome focuses on chemotherapy and indications for surgical intervention; however, there are few published recommendations for the anesthetic management of these patients. Preoperatively, patients with suprasellar tumors require optimization of electrolytes and hypothalamic hormones via proper supplementation, as well as a thorough physical examination.
Intraoperatively, patients with diencephalic syndrome (DS) presenting with cachexia are at increased risk for pressure injuries and hypothermia; therefore, proper positioning, padding of bony prominences, and maintenance of normothermia must be emphasized. Stress dose steroids should be considered in patients with low cortisol levels, and clinicians should maintain a high suspicion for diabetes insipidus. Additionally, dehydration and hypoalbuminemia are common in patients with DS, and fluid resuscitation beyond normal maintenance rates may be required.
Postoperatively, prevention of hypothermia and fluid management should continue. Patients may require admission to a critical care unit, followed by appropriate transition to the surgical floor and discharge home.
