https://doi.org/10.33698/NRF0290-Hemlata, Dhandapani M, Dhandapani SS, Chabbra R
ABSTRACT:
Background: Postoperative complications due to uid electrolyte imbalances in patients of sellar and suprasellar tumors are of major concern in patients as it leads to a signicant increase in morbidity and mortality. Objective: To nd out the common manifestation due to diabetes insipidus among postoperative patients of sellar and suprasellar tumors. Methodology: By using total enumeration technique, a descriptive study was conducted on 25 post-operative patients of sellar and suprasellar tumour admitted in the Neurosurgical units of PGIMER, Chandigarh from July- September 2018. The presence of diabetes insipidus in the postoperative patient of the sellar and suprasellar tumour was established by measuring hourly urine output, urine specic gravity, polyuria, serum sodium concentration, polydipsia/ increased thirst, dry mouth, tachycardia, fatigue/ restlessness, headache. Results: More than half (52%) of patients were in the age group between 25-50 years and more than half of the patients (56%) were male. Majority of the patients (72%) had pituitary tumours. Majority of the patients with sellar and suprasellar tumors had undergone endoscopic transnasal approach (76%), and 24% had undergone a trans-cranial approach. In the majority of patients, urine output was reported higher, i.e. more than 3000ml from rst to fth post operative day. The proportion of the patient with low urine specic gravity varied from40% to 52% from rst to fth post operative day. High prevalence of hypernatremia was reported, i.e. 44% on day 2nd, 48% on day 3rd, 32% on day 4th, 24% on day 5th and 8% on day 6thduring the post-operative period. Other signs and symptoms of diabetes insipidus among postoperative patients related to DI were polyuria(51%), polydipsia/ increased thirst(59%), dry mouth(64%%), fatigue/ restlessness(73%). Conclusion: Findings of the present study suggest that postoperative patients of sellar/ suprasellar tumour having various manifestations of DI including polyuria, low urine specic gravity, dysnatremia, fatigue/ restlessness, polydipsia, dry mouth in the initial postoperative days.
Keywords: ADH- anti diuretic hormone, diabetes insipidus, hypernatremia, pituitary sellar/ suprasellar tumors.
Address of correspondence: Dr. Manju Dhandapani (Lecturer, NINE) Postgraduate Institute of Medical and Educational Research, Chandigarh Email: manjuseban@gmail.com
Introduction
The incidences of sellar and suprasellar pituitary lesions are estimated approximately 10% of intracranial lesions.1 The tumors of the pituitary gland represent approximately 10% of diagnosed brain neoplasm. The transsphenoidal resection of pituitary tumors is approximately 20% of all intracranial operations performed for primary brain tumors. The most common tumors of the sellar and parasellar region are pituitary adenomas. Types of tumors that found in sellar or parasellar region include craniopharyngiomas, epidermoid cysts, germ cell tumors etc. and tumors arise from covering of the brain such as meningiomas and gliomas.1,2A review study conducted on postoperative patients of pituitary adenomas showed that common manifestations of diabetes insipidus (DI) reported by patients were polyuria and hypernatremia.3Areview study conducted on 1571 patients of pituitary adenoma surgery reported polyuria with hypernatremia in 38% of the patient and only polyuria in 31% of patients. A prospective controlled study conducted on 52 patients who underwent surgery for pituitary adenoma reported that 38% of the patients had isolated DI and 15.7% had combined DI followed by hyponatremia. 4Most of the studies conducted are on the patients with pituitary tumors, but have not included other conditions present in the sellar and suprasellar region. Hence the present study was conducted to nd out the common manifestations due to Diabetes insipidus among postoperative patients of sellar and suprasellar tumors.
Material and method: A prospective study was conducted in the neurosurgery units of PGIMER, Chandigarh. By using the total enumeration technique, 25 adult post- operative patients of sellar and suprasellar tumor from July- September 2018, who has consented, were enrolled in the study. Known case of diabetes insipidus, renal disorder, and chronic heart failure were excluded from the study. Patient proforma was used for data collection, which i ncluded socio- d e m o g r a p h i c a n d c l i n i c a l p r o l e , p h y s i o l o g i c a l m e a s u r e m e n t s , a n d observational checklist for manifestations of diabetes insipidus. Ethical approval was obtained f rom the Institute Ethics Committee, PGIMER, Chandigarh with the reference number NK/4328/M.Sc. For conducting the study, permission was taken from the Head Department, Neurosurgery PGIMER, Chandigarh. Informed consent was taken from the patients. The patient was enrolled on zero postoperative day and followed up till 6th postoperative days and on the previous day before discharge .On day zero, patient prole and the clinical prole was collected from hospitals records. Biophysiological measurement included serum sodium value, and urine specic gravity. Patients were observed for the manifestation of diabetes insipidus. The data were analyzed by using IBM SPSS (Statistical Package for Social Sciences) 23.0 versions by using descriptive and inferential statistics.
Results: Socio-demographic and clinical prole of postoperative sellar and suprasellar tumor patients were depicted in table 1. More than half numbers of patients (52%) were in the age group of 25- 50 years. More than half of the patients (56%) were male. Majority of the patients (64%) were non- vegetarian ,and more than half (52%) patients had percapita income between Rs. 2501-500.Majority of the patients had undergone endoscopic transnasal approach (76%), and one third (36%) of patients were on cortisone supplementation. Only 12% of the patients were known case of diabetes mellitus. More than half (56%) of patients were with normal body mass index (BMI). All patients had normal baseline blood urea and creatnine level. Majority of the patient (96%) had normal baseline serum sodium level in between 135-145 mEq/L.
As depicted in table 2 which shows the daily urine output, on the post-operative day zero, the majority (72%) of the patients had normal urine output between 1000-3000ml, but 24% of patients had also reported urine output less than 1000ml.Majority of patients had urine output more than 3000ml, i.e. 84%, 76%, 92%, 88%, 84%, 68% on post-operative day 1st to day 6th and previous day of before discharge respectively. Urine specic gravity of patients from day zero to post operative day 6th and the previous day before discharge are depicted in table 2. The proportion of the patient with low urine specic gravity varied from 40% to 52% from rst to fth post operative day. On post operative day 6th, 29% of patients had low specic gravity, and on the previous day before discharge, 16% of patients with low specic gravity. Low specic gravity (normal urine specic gravity <1.005) was reported in the higher proportion of the patients during the postoperative period. Hyponatremia was reported high (28%) on postoperative day 1st. There was a high prevalence of hypernatremia, i.e. 44% on day 2nd, 48% on day 3rd, 32% on day 4th, 24% on day 5th, and 8% on day 6th. Only one patient had hypernatremia on the previous day before discharge. Majority of the patient had normal serum sodium on all the postoperative days from day zero, day 1st, day 5th, day 6th, and the day before discharge
Table 1: Socio-demographic and clinical profile of postoperative sellar and suprasellar tumour patients
n=25
| Socio-demographicand Clinical profile | f (%) |
| Age (years)
Less than 25 25-50 51 and above |
8(32) |
| 13(52) | |
| 4(16) | |
| Gender | |
| Male | 14(56) |
| Female | 11(44) |
| Dietary habit | |
| Vegetarian | 8 (32) |
| Non-vegetarian | 16(64) |
| Eggitarian | 1(4) |
| Percapita Income(Rupees)
Less than 2500 2501-5000 >5000 |
9(36) |
| 13(52) | |
| 3(12) | |
| Types of tumour Pituitary tumour Craniopharyngioma |
18(78) |
| 7(22) | |
| Surgical Approach Endoscopic trans nasal Tran cranial
Diabetic mellitus On cortisol supplementation |
19(76) |
| 6(24) | |
| 3(12) | |
| 9(36) | |
| BMI (kg/m2)
Underweight (Below 18.5) Normal weight (18.5-24.9) Overweight (Above 25) |
2(8) |
| 14(56) | |
| 3(12) | |
| Baseline urea (mg/dl)
Less than 10 Normal urea (11-50) More than 50 |
0 |
| 25(100) | |
| 0 | |
| Baseline creatinine (mg/dl)
Low creatinine (<0.5) Normal creatinine (0.5-1.2) High creatinine (>1.2) |
0 |
| 25(100) | |
| 0 | |
| Baseline serum sodium (mEq/L)
Hyponatremia (<135) Normal serum sodium (135-145) Hypernatremia (>145) |
1(4) |
| 24(96) | |
| 0 |
Table 2: Urine output, urine specific gravity, and category of serum sodium among postoperative patients of sellar and supra sellar tumors n=25
| f(%) | |||||||||
| Post operative day | Day0 | Day 1st | Day
2nd |
Day 3rd | Day 4th | Day 5th | Day 6th | Day D# | |
| Urine output(ml) 24 hourly | |||||||||
| 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| Oliguria (<1000ml) | 6(24) | ||||||||
| Normal urine output (1000-3000) | 18(72) | 4(16) | 6(24) | 2(8) | 2(8) | 3 (12) | 4(16) | 8 (32) | |
| Polyuria (>3000) | 1(4) | 21(84) | 19(76) | 23(92) | 23(92) | 22(88) | 21(84) | 17(68) | |
| Urine specific gravity | . | ||||||||
| 14(56) | 10(40) | 13(52) | 10(40) | 7(28) | 4(16) | ||||
| Low (<1.005) | 2(8) | 10(40) | |||||||
| Normal (1.005-1.025) | 23(92) | 15(60) | 11(44) | 15(60) | 12(48) | 14(56) | 17(68) | 20(80) | |
| High (>1.025) | 0 | 0 | 0 | 0 | 0 | 1(4) | 0 | 1(4) | |
| Serum sodium | |||||||||
| 7 (28) | 3 (12) | 3 (12) | 4 (16) | 2 (8) | 3 (12) | 0 | |||
| Hyponatremia | 1(4) | ||||||||
| Normal | 22 (88) | 17 (68) | 11 (44) | 10 (40) | 13 (52) | 17 (68) | 20(80) | 24 (96) | |
| Hypernatremia | 2 (8) | 1 (4) | 11 (44) | 12 (48) | 8 (32) | 6 (24) | 2 ( 8) | 1 (4) | |
#previous day before discharge
Table 3: Common manifestation of DI among postoperative patients of sellar and
supra sellar tumors n=25
| Post operative
day |
f(%) | |||||||
| Day0 | Day 1st | Day 2nd | Day 3rd | Day 4th | Day 5th | Day 6th | Day D# | |
| Polyuria | 3(12) | 18(72) | 18(72) | 22(88) | 22(88) | 17(68) | 2(8) | 1(4) |
| Polydipsia | 8(32) | 19(76) | 20(80) | 20(80) | 21(84) | 15(62) | 11(45) | 3(12) |
| Dry mouth | 10(40) | 19(76) | 19(76) | 22(88) | 22(88) | 18(72) | 13(54) | 4(16) |
| Tachycardia | 0 | 2(8) | 3(12) | 5(20) | 3(12) | 4(16) | 3(12) | 0 |
| Fatigue | 18(72) | 22(88) | 21(84) | 20(80) | 21(84) | 22(88) | 15(62) | 6(24) |
#previous day before discharge
Polyuria on day zero was reported by only 12% of patients. But, the prevalence was very high from postoperative day 1st to day 5th, i.e. between 68-88%. On postoperative day 6th, only8% of the patients had polyuria and only one patient previous day before discharge reported polyuria (Table 3). Polydipsia/ increase thirst was reported by 32% on day 0, but the high prevalence of polydipsia i.e. 65% to 84%, was reported reported polydipsia on the previous day before discharge (table 3).Dry mouth was reported by 40% on day 0, but the high prevalence of dry mouth, 54% to 88% was reported from post operative day 1st to day 6th, again on the previous day before discharge, 16% of patient had reported dry mouth. Hence, the prevalence of dry mouth reported high among post-operative patient of the sellar suprasellar tumour. Tachycardia was from day 1st to day5th. Again on post- reported by 8% to 20% of patients from post operative day 6th, 45% of patients had reported polydipsia, and 12% of patients operative day 1st to day 6th as depicted in table
Fatigue/ restlessness was reported by 62% to 88% of patients from post operative day 0 to day 6th, as depicted in table 3. Again on the previous day before discharge, 24% of patients had reported fatigue/restlessness. Hence the prevalence of the fatigue and restlessness were high among postoperative patients of sellar and suprasellar tumors. The median duration of hospital stay of patients reported was18 days.
Discussion: Pituitary adenomas are the most common tumours of the sellar and parasellar region. Postoperative complications of patients of sellar and supra sellar tumour are of major concern in patients because it leads to a signicant increase in morbidity and mortality. Most of the studies conducted are on the patients with pituitary tumours, but have not included other conditions present in sellar and suprasellar region. Hence the need was felt to conduct a study to nd out the common manifestation of diabetes insipidus in postoperative patient of sellar and suprasellar tumour.
Evidences shows that DI is a common postoperative complication that occurs in 83% of patients with sellar and parasellar tumours.7 In present study, prevalence of polyuria was reported by 72 to 88% of the patients who were on routine care with signicantly higher urine output up to 4100 ml. Muhammad et al has reported median urine output up to 5750 ml in post operative patients of transsphenoidal surgery while the present study shows that median urine output range between 3540ml- 4150ml.8 A study shows that median urine output was 4540 ml on day 2 with DI10, while in present study median urine output were high (3540- 4150ml) in patients varied between 68- 92% slightly higher as compared to previous reports on DI showing the prevalence up to 57%.6 Patients had signicantly low urine specic gravity which shows the dilution of urine, may be due to reduced antidiuretic hormone level and increased uid consumption that resulted in increased urine output. In present study, high prevalence of hypernatremia was observed in patients from second to fth postoperative days. Simon et al has reported dysnatremia in 78% of the patients who underwent sellar/ suprasellar surgery9 while in present study had reported the same only in 48% of patients. A retrospective study conducted on 44 post operative patient of pituitary tumours reported 56% of patients developed polyuria during initial postoperative period11 while in present study, 88% of patients reported polyuria. The patients are found to consume juices and sugarated beverages during postoperative periods. There is lack of dietary management guidelines for DI among postoperative patients.
Findings of the present study suggest that postoperative patients of sellar/ suprasellar tumor having various manifestations of DI including polyuria, hyponatremia, fatigue/ restlessness, polydipsia and dry mouth in the initial post-operative days after surgery. So, nurses have an important role in identifying a n d m a n a g i n g c o m p l i c a t i o n s o f postoperative patients of the sellar suprasellar tumor with early screening and proper implementation of various evidence- based strategies. Present study throws light to develop appropriate management guidelines for post-operative patient with sellar and suprasellar tumour. To enhance better patient on postoperative day 2nd to day 6th.The outcome, nurses must educate and motivate prevalence of DI in the present study was the patients to follow an appropriate oral replacement that may prevent or reduce complications such as diabetes insipidus and hypernatremia.
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