31-year-old lady for Hysteroscopy, D&C, Ablation, and Laparoscopic Bilateral Oophorectomy
- Chronic pelvic pain, recurrent ovarian cysts
- Menorrhagia and anaemia, known to Gynaecologist for many years
- Multiple previous hysteroscopies and laparoscopies
- Decision to have oophorectomy made the day prior to clinic review via preoperative phoneconsult with proceduralist
- Recent referral to chronic pain specialist, review pending
- Partially Empty Sella syndrome – ACTH, TSH, and Prolactin deficiency
- On high-dose Hydrocortisone
- Previous Addisonian crisis perioperatively despite steroid replacement regime?
- Severe untreated GORD
- Procedure booked for private hospital with no onsite endocrinology support
- Very fit and healthy lady despite co-morbidities. DASI >10
What is Partially Empty Sella?
- Empty sella – Radiological description. Pituitary gland shrinks/is compressed by CSF making the sella look empty.
- Partial empty sella – remnants of the pituitary gland visible on MRI
- Rare condition, congenital. Mainly affects women
- Hypopituitarism – mainly deficiencies of anterior pituitary hormones.
- Common manifestations are Central hypogonadism and female infertility.
Perioperative management of Addison’s
- Maintain hydration and regular steroid replacement
- Monitor electrolytes and BSL
- IV hydrocortisone replacement at start of surgery – dose dependent on surgery and duration of fasting
- IV hydrocortisone replacement in first 24 hours after intermediate and major surgery
- Endocrinologist advice recommended. See attached BJA education paper
Suitable for Private Hospital?
- Consensus was no, surgery should be rescheduled to occur at JHH
- Endocrinologist in agreement, should be in hospital where they are available to consult
- Proceed at JHH
- Steroid replacement regime in conjunction with endocrine
- Recheck pathology including TFT’s
- Commence PPI
- See article Anaesthesia and Pituitary Disease doi:10.1093/bjaceaccp/mkr014