Patient Experience and Adherence to a Fluid Restriction Protocol after Transsphenoidal Surgery

Introduction: Delayed hyponatremia represents the most common cause of readmission following endoscopic transsphenoidal surgery (TSS), affecting up to 30.7% of all cases, and thought to be a result of unregulated vasopressin release postoperatively. Even with recent studies evaluating predictive factors for delayed hyponatremia, no consistent predictors have been identified. Some pituitary centers, including ours, have implemented preventative postoperative fluid restriction in an effort to reduce hyponatremia and readmissions.

Objective: To analyze the outcomes, patient reported experience and adherence of a prospective cohort of patients undergoing TSS for sellar lesions who underwent fluid restriction using an institutional review board approved survey.

Methods: All consecutive patients without diabetes insipidus harboring pituitary adenomas, craniopharyngiomas, and cystic lesions operated on by three skull-base neurosurgeons via TSS were included in the protocol from January 2021 to January 2023. Patients were educated on fluid restriction to 32 oz (1,000 mL) of clear liquid per day from postoperative days (PODs) 4 to 8. Serum sodium levels were collected preoperatively, on POD1 and POD8. For a control group, we retrospectively analyzed a cohort (November 2016 to December 2020) operated on by the same neurosurgeons prior to implementation of fluid restriction. Upon discharge, patients were given a survey to document their adherence/experience.

Results: Three hundred and sixty-one TSS cases were performed during the study period; 271 patients met inclusion criteria. Of these, 127 comprised the retrospective control group (no fluid restriction), and 144 were instructed to implement fluid restriction. From the control group analysis, 6 readmissions due to hyponatremia were identified (4.7%), all of which had adenomas as the primary diagnosis. In the fluid restricted group, 3 patients (2%) were readmitted which included 2 cystic lesions and a patient with lymphocytic hypophysitis. Mean sodium levels at POD8 were 137.7 mg/dL without fluid restriction and 139 mg/dL for the fluid restricted cohort. Considering only patients with adenomas, the risk of readmission was reduced to 0% ( p  =  0.009, 95% CI: 0–0.56 ). No hypernatremia, abnormalities in renal parameters, or other complications occurred with fluid restriction. A total of 12 standardized surveys were obtained to evaluate patient adherence and feedback. Ten patients (83.33%) strictly adhered to the restriction plan, while 2 patients ingested a mean of 8 and 16 oz more than expected per day, respectively. The mean reported amounts of fluid ingested per day were 34.8, 36.9, 33.8, 33.7, and 34.1 oz, from POD4 to 8, respectively. Second day of fluid restriction (POD5) was considered the most challenging in terms of adherence and thirst level as reported by patients.

Conclusion: Postoperative fluid restriction in patients undergoing transsphenoidal surgery is a safe and effective method to prevent delayed hyponatremia, the most common and costliest postoperative complication in this patient population. According to a patient-reported survey, compliance and understanding of the protocol was high but the second day of fluid restriction appeared to be the hardest in terms of protocol adherence and symptoms. Future prospective studies will aid in clarifying the effectiveness of fluid restriction on non-adenomatous cystic lesions and pituitary inflammatory disorders.

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Artikel online veröffentlicht:
07. Februar 2025