Persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery: A case report

BACKGROUND

Empty sella is an anatomical and radiological finding of the herniation of the subarachnoid space into the pituitary fossa leading to a flattened pituitary gland. Patients with empty sella may present with various symptoms, including headache due to intracranial hypertension and endocrine symptoms related to the specific pituitary hormones affected. Here, we report a female patient who developed persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery.

CASE SUMMARY

A 47-year-old woman underwent vocal cord polypectomy under general anesthesia with endotracheal intubation. She denied any medical history, and her vital signs were normal before the surgery. Anesthesia and surgery were uneventful. However, she developed dizziness, headache and persistent hypotension in the ward. Thus, intravenous dopamine was started to maintain normal blood pressure, which improved her symptoms. However, she remained dependent on dopamine for over 24 h without any obvious anesthesia- and surgery-related complications. An endocrine etiology was then suspected, and further examination showed a high prolactin level, a low normal adrenocorticotropic hormone level and a low cortisol level. Magnetic resonance imaging of the brain revealed an empty sella. Therefore, she was diagnosed with empty sella syndrome and secondary adrenal insufficiency. Her symptoms disappeared one week later after daily glucocorticoid supplement.

CONCLUSION

Endocrine etiologies such as pituitary and adrenal-related dysfunction should be considered in patients showing persistent postoperative hypotension when anesthesia- and surgery-related factors are excluded.

Breaking Down the Evidence: Does Perioperative Hypotension Cause Kidney Injury?

BACKGROUND

Acute kidney injury (AKI) is common in the postoperative period and is associated with negative patient outcomes. The definition of perioperative hypotension is wide, but it is associated with various complications, including AKI.

SUMMARY

Preclinical data suggest that sustained severe renal hypoperfusion per se does not cause persistent AKI. The evidence associating blood pressure levels and postoperative renal dysfunction is predominantly retrospective and observational, and therefore potentially misled by the complex interactions between exposures, confounders, and mediators.

KEY MESSAGES

To better understand how perioperative hemodynamic management could affect the occurrence of kidney injury, it is pivotal to further investigate the association between hypotension and kidney dysfunction in the perioperative period and determine the degree to which hypotension is a causal factor.

Association of perioperative hypotension with subsequent greater healthcare resource utilization

STUDY OBJECTIVE

Determine if perioperative hypotension, a modifiable risk factor, is associated with increased postoperative healthcare resource utilization (HRU).

DESIGN

Retrospective cohort study.

SETTING

Multicenter using the Optum® electronic health record database.

PATIENTS

Patients discharged to the ward after non-cardiac, non-obstetric surgeries between January 1, 2008 and December 31, 2017 with six months of data, before and after the surgical visit.

INTERVENTIONS/EXPOSURE

Perioperative hypotension, a binary variable (presence/absence) at an absolute MAP of ≤65-mmHg, measured during surgery and within 48-h after, to dichotomize patients with greater versus lesser hypotensive exposures.

MEASUREMENTS

Short-term HRU defined by postoperative length-of-stay (LOS), discharge to a care facility, and 30-day readmission following surgery discharge. Mid-term HRU (within 6 months post-discharge) quantified via number of outpatient and emergency department (ED) visits, and readmission LOS.

MAIN RESULTS

42,800 distinct patients met study criteria and 37.5% experienced perioperative hypotension. After adjusting for study covariates including patient demographics and comorbidities, patients with perioperative hypotension had: longer LOS (4.01 vs. 3.83 days; LOS ratio, 1.05; 95% CI, 1.04-1.06), higher odds of discharge to a care facility (OR, 1.18; 95% CI, 1.12-1.24; observed rate 22.1% vs. 18.1%) and of 30-day readmission (OR, 1.22; 95% CI, 1.11-1.33; observed rate 6.2% vs. 5.0%) as compared to the non-hypotensive population (all outcomes, p < 0.001). During 6-month follow-up, patients with perioperative hypotension showed significantly greater HRU regarding number of ED visits (0.34 vs. 0.31 visits; visit ratio, 1.10; 95% CI, 1.05-1.15) and readmission LOS (1.06 vs. 0.92 days; LOS ratio, 1.15; 95% CI, 1.07-1.24) but not outpatient visits (10.47 vs. 10.82; visit ratio, 0.97; 95% CI, 0.95-0.99) compared to those without hypotension. There was no difference in HRU during the 6-month period before qualifying surgery.

CONCLUSIONS

We report a significant association of perioperative hypotension with an increase in HRU, including additional LOS and readmissions, both important contributors to overall medical costs.

Stratification and Risk Reduction of Perioperative Acute Kidney Injury: An Update

Perioperative acute kidney injury is associated with morbidity and mortality. Several definitions have been proposed, incorporating small changes of serum creatinine and urinary output reduction as diagnostic criteria. In the surgical patient, comorbidities, type and timing of surgery, and nephrotoxins are important. Patient comorbidities remain a significant risk factor. Urgent or emergent surgery and cardiac or transplantation procedures are associated with a higher risk of acute kidney injury. Nephrotoxic drugs, contrast dye, and diuretics worsen preexisting kidney dysfunction or act as an adjunctive insult to perioperative injury. This review includes preoperative, intraoperative, and postoperative issues that can be mitigated.