title: Factors predicting postoperative hyponatremia and efficacy of hyponatremia management strategies after more than 1000 pituitary operations.
abstract: OBJECTIVE
  Syndrome of inappropriate antidiuretic hormone secretion-induced hyponatremia is a common morbidity after pituitary surgery that can be profoundly symptomatic and cause costly readmissions. The authors calculated the frequency of postoperative hyponatremia after 1045 consecutive operations and determined the efficacy of interventions correcting hyponatremia.
  
  
  METHODS
  The authors performed a retrospective review of 1045 consecutive pituitary surgeries in the first 946 patients treated since forming a dedicated pituitary center 5 years ago. Patients underwent preoperative and daily inpatient sodium checks, with outpatient checks as needed.
  
  
  RESULTS
  Thirty-two patients presented with hyponatremia; 41% of these patients were symptomatic. Postoperative hyponatremia occurred after 165 operations (16%) a mean of 4 days after surgery (range 0-28 days); 19% of operations leading to postoperative hyponatremia were associated with postoperative symptoms (38% involved dizziness and 29% involved nausea/vomiting) and 15% involved readmission for a mean of 5 days (range 1-20 days). In a multivariate analysis including lesion size, age, sex, number of prior pituitary surgeries, surgical approach, pathology, lesion location, and preoperative hypopituitarism, only preoperative hypopituitarism predicted postoperative hyponatremia (p = 0.006). Of patients with preoperative hyponatremia, 59% underwent medical correction preoperatively and 56% had persistent postoperative hyponatremia. The mean correction rates were 0.4 mEq/L/hr (no treatment; n = 112), 0.5 mEq/L/hr (free water restriction; n = 24), 0.7 mEq/L/hr (salt tablets; n = 14), 0.3 mEq/L/hr (3% saline; n = 20), 0.7 mEq/L/hr (intravenous vasopressin receptor antagonist Vaprisol; n = 22), and 1.2 mEq/L/hr (oral vasopressin receptor antagonist tolvaptan; n = 9) (p = 0.002, ANOVA). While some patients received more than 1 treatment, correction rates were only recorded when a treatment was given alone.
  
  
  CONCLUSIONS
  After 1045 pituitary operations, postoperative hyponatremia was associated exclusively with preoperative hypopituitarism and was most efficiently managed with oral tolvaptan, with several interventions insignificantly different from no treatment. Promptly identifying hyponatremia in high-risk patients and management with agents like tolvaptan can improve safety and decrease readmission. For readmitted patients with severely symptomatic hyponatremia, the intravenous vasopressin receptor antagonist Vaprisol is another treatment option.
authors: Department of Neurosurgery and California Center for Pituitary Disorders, University of California, San Francisco, California.
authors: Arman
authors: A
authors: Jahangiri
authors: Jeffrey
authors: J
authors: Wagner
authors: Mai T
authors: MT
authors: Tran
authors: Liane M
authors: LM
authors: Miller
authors: Maxwell W
authors: MW
authors: Tom
authors: Sandeep
authors: S
authors: Kunwar
authors: Lewis
authors: L
authors: Blevins
authors: Manish K
authors: MK
authors: Aghi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D065092:Antidiuretic Hormone Receptor Antagonists; D001552:Benzazepines / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007010:Hyponatremia / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology*; D007018:Hypopituitarism / Q000453:epidemiology / Q000601:surgery*; D007177:Inappropriate ADH Syndrome / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D010902:Pituitary Gland / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D012964:Sodium / Q000097:blood; D000077602:Tolvaptan; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D065092:Antidiuretic Hormone Receptor Antagonists; D001552:Benzazepines; C106389:conivaptan; D000077602:Tolvaptan; D012964:Sodium