What is the acute management for a 31‑year‑old male post‑transsphenoidal pituitary surgery presenting with a focal clonic seizure, mild hyponatremia, secondary hypothyroidism, possible secondary adrenal insufficiency, pre‑renal acute kidney injury, hypertension, type 2 diabetes, and community‑acquired pneumonia?

Acute Management of Post-Transsphenoidal Surgery Patient with Seizure and Multiple Complications

Immediately administer hydrocortisone 100 mg IV bolus without waiting for any confirmatory testing, followed by continuous infusion of 200 mg over 24 hours, as this patient with prior pituitary surgery presenting with altered mental status, hyponatremia, and secondary hypothyroidism has presumed secondary adrenal insufficiency until proven otherwise—a life-threatening condition that must never have treatment delayed. 1, 2

Immediate Priorities (First Hour)

1. Address Potential Adrenal Crisis

• Administer hydrocortisone 100 mg IV bolus immediately without waiting for cortisol levels or ACTH stimulation testing 1, 2
• Follow with continuous infusion of 200 mg hydrocortisone over 24 hours (or 50 mg IV every 6 hours as alternative) 1, 2
• This patient has multiple red flags for adrenal insufficiency: post-pituitary surgery, secondary hypothyroidism (FT3 2.04, FT4 0.52—both low), hyponatremia (133 mmol/L), and acute illness with altered consciousness 1
• Volume-resistant hypotension and altered mental status are cardinal features of impending adrenal crisis, and somnolence with decreasing verbal output represents early warning signs 1
• Mortality is extremely high if adrenal crisis remains untreated, and treatment should NEVER be delayed for diagnostic procedures 2, 3

2. Seizure Management

• Administer lorazepam 4 mg IV slowly (2 mg/min) for ongoing or recurrent seizure activity 4
• If seizures continue after 10-15 minutes, give additional 4 mg IV dose slowly 4
• Maintain patent airway with equipment immediately available, as benzodiazepines can cause respiratory depression 4
• Correct hyponatremia cautiously as it is a known precipitant of seizures, particularly in post-neurosurgical patients 1
• Note that hypocalcemia can trigger seizures in pituitary patients at any age—check ionized calcium urgently 1

3. Fluid Resuscitation and Hyponatremia Management

• Infuse 0.9% normal saline at 1 L/hour for at least 2 liters total to address pre-renal AKI (creatinine 190.76 µmol/L) and potential volume depletion 3, 5
• The hyponatremia (133 mmol/L) is mild and likely multifactorial: secondary adrenal insufficiency, SIADH from pneumonia, and poor oral intake 1, 6
• Do NOT restrict fluids in this patient with pre-renal AKI and potential adrenal insufficiency—fluid restriction is contraindicated and dangerous 1, 5
• Isotonic saline corrects both pre-renal AKI and hyponatremia without risk of overly rapid correction 5
• Monitor sodium every 4-6 hours; correction should not exceed 8-10 mmol/L in first 24 hours to avoid osmotic demyelination 1

Secondary Management (First 24 Hours)

4. Antibiotic Therapy for Community-Acquired Pneumonia

• Initiate broad-spectrum antibiotics immediately for high-risk CAP (pansinusitis on CT, elevated CRP 1.70) 6
• Hyponatremia is present in 27.9% of CAP patients at admission and associated with greater severity of illness and mortality 6
• Continue isotonic saline as initial IV fluid choice, as hypotonic fluids increase risk of iatrogenic hyponatremia 6

5. Thyroid Hormone Replacement

• Continue levothyroxine 100 mcg daily (patient's home dose) 1
• Do NOT increase thyroid hormone acutely, as this can precipitate adrenal crisis in patients with untreated adrenal insufficiency 1
• Secondary hypothyroidism (low FT3 and FT4 with normal TSH 2.24) confirms pituitary dysfunction 1

6. Monitoring for Adrenal Crisis Evolution

• Check sitting and supine blood pressure every 2-4 hours to detect orthostatic hypotension (early sign of adrenal insufficiency) 1
• Monitor for non-specific malaise, somnolence, obtunded consciousness, and cognitive dysfunction 1
• Do NOT reduce or withdraw steroid supplementation while patient remains febrile or critically ill, as persistent pyrexia may be due to adrenal insufficiency itself 1
• Serial electrolytes including sodium, potassium, and glucose every 4-6 hours 1

7. Diabetes Management

• Monitor blood glucose closely as hydrocortisone will cause hyperglycemia 1
• Use insulin sliding scale or infusion to maintain glucose 7-10 mmol/L 1
• Glucocorticoid-induced hyperglycemia is easily controlled and should not deter appropriate steroid dosing 1

Critical Pitfalls to Avoid

• Never delay hydrocortisone administration to obtain cortisol levels or perform ACTH stimulation testing in a critically ill post-pituitary surgery patient 1, 2
• Never restrict fluids in a patient with hyponatremia and concurrent pre-renal AKI—this worsens both conditions 1, 5
• Never use hypotonic IV fluids (D5W, 0.45% saline) in this patient, as they will worsen hyponatremia iatrogenically 6, 7
• Never reduce steroid dose while patient remains febrile, altered, or hemodynamically unstable 1
• Never assume normal adrenal function in a post-transsphenoidal surgery patient with secondary hypothyroidism—these patients have pituitary dysfunction affecting multiple axes 1

Transition to Oral Therapy (After 48-72 Hours)

• Once patient tolerates oral intake and is clinically stable, transition to oral hydrocortisone 15-25 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg evening) 1
• Taper stress-dose steroids gradually over 3-5 days as clinical condition improves 1
• Patient must receive steroid emergency card and medical alert bracelet before discharge 3, 8
• Educate patient to double or triple glucocorticoid dose during future illness, fever, or stress 3

Definitive Workup (After Stabilization)

• Formal pituitary function testing including morning cortisol, ACTH, growth hormone, prolactin, LH, FSH, testosterone (if male) 1
• MRI brain with pituitary protocol to assess surgical bed and residual/recurrent adenoma 1
• Endocrinology consultation for long-term hormone replacement optimization 1