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Pathophysiology and management of pituitary disorders in the critically ill 

Pathophysiology and management of pituitary disorders in the critically ill
Chapter:
Pathophysiology and management of pituitary disorders in the critically ill
Author(s):

Yves Debaveye

and Greet Van den Berghe

DOI:
10.1093/med/9780199600830.003.0262
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date: 01 December 2020

The pituitary gland plays a predominant role in the endocrine system. Consequently, patients with pituitary diseases or after pituitary surgery present unique challenges to the intensivist. Failure of the anterior pituitary gland to secrete one or more pituitary hormones results in a clinical syndrome known as hypopituitarism. While hypopituitarism is mostly encountered in patients in whom the diagnosis has already been made, acute exacerbation of an undiagnosed insufficiency may occasionally occur. Acute decompensated patients with suspected hypopituitarism should be admitted to an intensive care unit for haemodynamic stabilization, replacement of missing hormones, and identification and treatment of the causative stressor. Prompt administration of hydrocortisone is the single most important acute medical intervention in hypopituitaric patients. Failure of the posterior pituitary to secrete antidiuretic hormone results in diabetes insipidus (DI). DI is characterized by excess volumes of severely diluted urine, which can lead to hyperosmolality and hypernatraemia as many critically-ill patients do not have free access to oral fluids due to obtundation or sedation. Management of DI includes the correction of free water deficit and the reduction of polyuria with desmopressin. The post-operative care following pituitary surgery focuses on vigilant observation for neurosurgical complications (visual loss, meningitis, and cerebrospinal fluid leakage) and monitoring of neuroendocrinological perturbations (hypopituitarism and disorders of water balance, such as DI and SIADH). SIADH presents with hyponatremia, hypo-osmolality, and inappropriately concentrated urine in a setting of euvolaemia and can be managed in most cases by fluid restriction. Potential disruption of the pituitary-adrenal function is covered with peri-operative glucocorticoids.

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