LETTER TO EDITOR
Year : 2013 | Volume
: 57 | Issue : 1 | Page : 88--89
Laparoscopic appendicectomy in a child with multiple pituitary hormone deficiency
S Bala Bhaskar, BP Mallanna, Chetana Arun, D Srinivasalu
Department of Anaesthesiology and Critical Care, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, India
S Bala Bhaskar
Department of Anaesthesiology and Critical Care, Vijayanagar Institute of Medical Sciences (VIMS), Bellary, Karnataka
|How to cite this article:|
Bhaskar S B, Mallanna B P, Arun C, Srinivasalu D. Laparoscopic appendicectomy in a child with multiple pituitary hormone deficiency.Indian J Anaesth 2013;57:88-89
|How to cite this URL:|
Bhaskar S B, Mallanna B P, Arun C, Srinivasalu D. Laparoscopic appendicectomy in a child with multiple pituitary hormone deficiency. Indian J Anaesth [serial online] 2013 [cited 2020 Sep 26 ];57:88-89
Available from: http://www.ijaweb.org/text.asp?2013/57/1/88/108586
We report the anaesthetic management of an 11-year-old male patient with multiple pituitary hormone deficiency (MPHD) posted for laparoscopic appendicectomy for acute appendicitis.
History revealed that he was born with congenital left microphthalmos. Birth history and maternal obstetric history were normal. At 6 years of age, due to complaints of mouth breathing, child was subjected to magnetic resonance imaging (MRI) and was found to have frontoethmoidal encephalocoele; pituitary gland and optic chiasm were unidentifiable. Trans-nasal resection and repair of anterior cranial fossa floor was carried out with relief of symptoms. After 2 years, during work-up for complaints of delayed growth, investigations revealed MPHD (reduction in values for age of serum cortisol, insulin-like growth factor (IGF-1), adrenocorticotrophic hormone (ACTH) and thyroid hormones); pituitary was seen in the normal position in MRI. Bone age to chronological age was less by 2 years on X-ray and bone mineral density was low; child was started on growth hormone (GH) (subcutaneous), glucocorticoid, thyroid and vitamin D supplementation. Steroid supplementation was withdrawn after 2 years due to normalization of serum cortisol.
Preoperatively, the child's height and weight were below normal for age (reference CDC Growth Chart) and cortisol, free T3, free T4, thyroid-stimulating hormone (TSH), IGF-1, blood glucose and electrolytes were within normal limits. The patient was kept nil orally and was on IV Ringer lactate. Informed and written consent was obtained from parents. Hydrocortisone 50 mg was given intravenously pre-induction, repeated after 8 hours. General anaesthesia was induced with fentanyl-thiopentone followed by vecuronium-facilitated intubation using a cuffed endotracheal tube (6.5 mm). Maintenance was done with oxygen-nitrous oxide and isoflurane 0.4%. Port entry sites were infiltrated with bupivacaine 0.25%. Haemodynamics were maintained within acceptable limits during pneumoperitoneum (limited to 14 mmHg) with isoflurane up to 0.8% and ventilatory rate adjusted to target end-tidal CO2 (ETCO2) of 35 mmHg. Reversal of muscle blockade was achieved using neostigmine-glycopyrolate. Extubation and recovery were uneventful. Monitoring included non-invasive blood pressure, pulse-oximetry, electrocardiogram, ETCO 2 and urine output. Diclofenac (suppository) was used for post-operative analgesia. Urine output was normal and the patient resumed oral intake and routine hormonal supplements after 12 hours. Repeat evaluations of thyroid functions, blood sugar, serum cortisol and electrolytes on second postoperative day were normal (IGF-1 was not assayed).
MPHD can be congenital (genetically mediated) or acquired (due to injury to hypothalamus, pituitary stalk, or anterior pituitary by space occupying lesions, infections and trauma).  In acquired variety, the patient is initially healthy and over years, features of pituitary insufficiency start. Atrophy of the adrenal cortex, thyroid and gonads is observed with delayed growth, hypothyroidism and tendency for hypoglycaemia. Height may be affected depending on age of onset and duration.
Diagnosis of GH deficiency is indicated by low serum levels of IGF-I and GH-dependent IGF-BP3 (35.2 ng/ml initially, N182-780 at 6 years); definite diagnosis is by absent/low levels of GH in response to some stimulants.  Low levels of TSH, T3, T4, ACTH, cortisol, gonadal steroids, etc., are observed.
Longer the duration of GH deficiency, more is the delay in skeletal maturation; bone age tends to be approximately 75% of chronologic age with deficient bone mineralization.  Replacement is by recombitant GH (somatropin) and correction of other hormonal deficiencies (thyroid hormone, steroids). Somatotropin is endogenous GH and Somatropin is recombinant GH. Dose adjustments are done based on growth and serum levels, which were done in the present case over 4 years. Normally, GH and cortisol (ACTH-stimulated release) are secreted in more amounts in response to surgical stimulus; TSH is not affected significantly.  GH stimulates release of smaller hormones, the IGF especially, the IGF-1 (from peripheral tissues) for its action. Bone mineralization and age-based bone growth can be checked and related to levels of GH/IGF-1.  GH deficiency affects body composition, physical performance and substrate metabolism and its replacement attenuates these effects; short-term and long-term effects of replacement may be significant.  It is important to remember the physiological effects of deficiency of the hormones in the peri-operative period. In the absence of adequate correction of the hormonal deficits, effects on glycaemic status, metabolism, water and electrolyte balance, immune status, etc., may be primarily affected with subsequent involvement of multiple organs. These can have a bearing on anaesthetic management of patients coming for incidental surgeries. Adequate replacement with monitoring of laboratory values in the preoperative period is imperative. Steroids in MPHD are stopped in the absence of symptoms of deficiency. Supplementation is advised during illness or preoperatively and hence hydrocortisone was administered before induction in the present case. 
No definite technique of anaesthesia is discussed in the literature in patients with pan-hypopituitarism posted for incidental surgeries under laparoscopy. In congenital type with decreased bone growth, neuraxial blocks could be difficult or contraindicated. 
The optimization of the hormonal levels removes risks associated with individual hormonal deficiencies and their effects on homeostasis both intra and postoperatively. Choice of anaesthetic agents and relaxants is based on the actual status of patient at the time of anaesthetic intervention. Etomidate is not the ideal choice if adrenal hyposecretion is a factor. It is advisable to consider the patient as not just being GH deficient but also hypoadrenal and hypothyroidal and take measures accordingly. Control of oxygenation and ventilation with careful monitoring of fluid administration during laparoscopy can avoid potential catastrophes associated with either low or exaggerated levels of the various pituitary hormones. Monitored optimization of hormones and careful modification of physiology in the perioperative period are thus associated with successful outcome in patients with MPHD presenting for incidental surgeries.
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