What is the risk stratification and required preoperative testing for a 49-year-old female with hypertension, hypothyroidism, hyperlipidemia, and prediabetes undergoing endoscopic/transsphenoidal resection of a pituitary mass?

From the Guidelines

For a 49-year-old female with hypertension, hypothyroidism, hyperlipidemia, and prediabetes undergoing endoscopic transsphenoidal resection of a pituitary mass, I recommend intermediate risk stratification with targeted preoperative testing. This patient should have a comprehensive metabolic panel, complete blood count, thyroid function tests (TSH, free T4), and an electrocardiogram, as suggested by the guidelines for perioperative care 1. Given her cardiovascular risk factors, a baseline ECG is important to assess for any underlying cardiac abnormalities, and her thyroid function must be optimized before surgery as hypothyroidism can affect anesthetic requirements and recovery. Pituitary hormone testing should include morning cortisol, ACTH, prolactin, growth hormone, IGF-1, LH, FSH, and estradiol to establish baseline pituitary function and identify any hormonal hypersecretion from the mass. Blood glucose monitoring is necessary due to her prediabetes, as surgical stress can worsen glycemic control, with a target range for blood glucose in the perioperative period of 100–180 mg/dL (5.6–10.0 mmol/L) 1. The patient should continue her antihypertensive medications through the morning of surgery with a sip of water, but may need to hold diuretics, and thyroid replacement should be maintained without interruption. This targeted approach balances the need to identify significant perioperative risks while avoiding unnecessary testing, focusing on her specific comorbidities and the nature of pituitary surgery which carries risks of hormonal disruption and potential diabetes insipidus postoperatively. Key considerations for her perioperative care include:

• Preoperative risk assessment for people with diabetes who are at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure 1
• Optimization of blood glucose levels before surgery, with an A1C target of <8% (63.9 mmol/L) whenever possible 1
• Holding metformin on the day of surgery and discontinuing SGLT2 inhibitors 3–4 days before surgery 1
• Monitoring blood glucose at least every 2–4 h while the individual takes nothing by mouth and dosing with short- or rapid-acting insulin as needed 1

From the Research

Risk Stratification

The patient's risk stratification can be determined using the American Society of Anesthesiologists (ASA) score, which is a widely used system for evaluating a patient's physical status before surgery. Based on the patient's medical history, including hypertension, hypothyroidism, hyperlipidemia, and prediabetes, her ASA score would likely be classified as ASA 2 or 3, indicating mild to severe systemic disease [ 2 ].

Preoperative Testing

The following preoperative tests may be required for the patient:

• Complete blood count (CBC) to evaluate for any bleeding disorders or anemia
• Basic metabolic panel (BMP) to assess electrolyte levels and kidney function
• Liver function tests (LFTs) to evaluate liver function
• Coagulation studies (PT/INR, PTT) to assess bleeding risk
• Electrocardiogram (ECG) to evaluate cardiac function
• Chest X-ray to evaluate lung function
• Thyroid function tests (TFTs) to assess thyroid hormone levels, given the patient's history of hypothyroidism [ 3 ]
• Lipid profile to assess cholesterol and triglyceride levels, given the patient's history of hyperlipidemia
• Fasting blood glucose or hemoglobin A1c (HbA1c) to assess blood sugar control, given the patient's history of prediabetes
• Blood pressure monitoring to assess blood pressure control, given the patient's history of hypertension

Additional Considerations

The patient's medical history and current medications should be carefully reviewed to identify any potential interactions or complications that may arise during surgery [ 4 ]. The anesthesiologist and surgical team should be informed of the patient's medical history and any concerns or potential risks.

Surgical Approach

The endoscopic transsphenoidal approach is a minimally invasive procedure that can be used to remove pituitary tumors [ 5 ]. This approach has been shown to be effective and safe, with minimal complications. However, the patient's individual circumstances and medical history should be taken into account when determining the best surgical approach.

Perioperative Care

A customized checklist can be used to ensure that all necessary steps are taken during the perioperative period to minimize the risk of adverse events [ 6 ]. This checklist can include items such as:

• Review of the patient's medical history and current medications
• Assessment of the patient's physical status and ASA score
• Review of laboratory results and imaging studies
• Confirmation of the surgical plan and approach
• Verification of the patient's identity and surgical site
• Administration of preoperative medications and antibiotics as needed
• Monitoring of the patient's vital signs and blood pressure during surgery
• Postoperative care and monitoring in the intensive care unit (ICU) or post-anesthesia care unit (PACU) as needed.