Empiric fluid restriction cuts transsphenoidal surgery readmissions

 

CHICAGO – A 70% drop in 30-day readmissions following transsphenoidal surgery was achieved at the University of Colorado, Aurora, after endocrinologists there restricted fluid for the first 2 weeks postop, according to a report at the Endocrine Society annual meeting.

The antidiuretic hormone (ADH) rebound following pituitary adenoma resection often leads to fluid retention, and potentially dangerous hyponatremia, in about 25% of patients. It’s the leading cause of readmission for this procedure, occurring in up to 15% of patients.

To counter the problem, endocrinology fellow Kelsi Deaver, MD, and her colleagues limited patients to 1.5 L of fluid for 2 weeks after discharge, with a serum sodium check at day 7. If the sodium level was normal, patients remained on 1.5 L until the 2-week postop visit. If levels trended upward – a sign of dehydration – restrictions were eased to 2 or even 3 L, which is about the normal daily intake. If sodium levels trended downward, fluids were tightened to 1-1.2 L, or patients were brought in for further workup. The discharge packet included a 1.5-L cup so patients could track their intake.

Among 118 patients studied before the protocol was implemented in September 2015, 9 (7.6%) were readmitted for symptomatic hyponatremia within 30 days. Among 169 studied after the implementation of the fluid restriction protocol, just 4 (2.4%) were readmitted for hyponatremia (P = .044).

“What was surprising is that we did not have any readmissions for dehydration/hypernatremia. That was the biggest [concern] among physicians, that we are going to dry out these patients and they would come back severely dehydrated. We didn’t see that.” With the protocol’s success, “this is now the routine management that all our endocrinologist attendings use,” Dr. Deaver said.

At present, there are no widely accepted postop fluid management guidelines for transsphenoidal surgery, but some hospitals have taken similar steps, she said.

It was the fluid restriction, not the 7-day sodium check, that drove the results. Among the four readmissions after the protocol took effect, two patients had their sodium checked, and two did not because their sodium drop was so precipitous that they were back in the hospital before the week was out. Overall, only about 70% of patients got their sodium checked as instructed.

 

Fluid restriction isn’t easy for patients. “The last day before discharge, we try to coach them through it,” with tips about sucking on ice chips and other strategies; “anything really to help them through it,” Dr. Deaver said.

Readmitted patients were no different from others in terms of pituitary tumor subtype, tumor size, gender, and other factors. “We couldn’t find any predictors,” she said. There were a higher percentage of macroadenomas in the preimplementation patients (91.5% versus 81.7%), but they were otherwise similar to postimplementation patients.

Those with evidence of diabetes insipidus at discharge were excluded from the study.

The National Institutes of Health funded the study. The investigators did not have any disclosures.

[email protected]

SOURCE: Deaver KE et al. Endocrine Society 2018 annual meeting abstract SUN-572.

 

CHICAGO – A 70% drop in 30-day readmissions following transsphenoidal surgery was achieved at the University of Colorado, Aurora, after endocrinologists there restricted fluid for the first 2 weeks postop, according to a report at the Endocrine Society annual meeting.

The antidiuretic hormone (ADH) rebound following pituitary adenoma resection often leads to fluid retention, and potentially dangerous hyponatremia, in about 25% of patients. It’s the leading cause of readmission for this procedure, occurring in up to 15% of patients.

To counter the problem, endocrinology fellow Kelsi Deaver, MD, and her colleagues limited patients to 1.5 L of fluid for 2 weeks after discharge, with a serum sodium check at day 7. If the sodium level was normal, patients remained on 1.5 L until the 2-week postop visit. If levels trended upward – a sign of dehydration – restrictions were eased to 2 or even 3 L, which is about the normal daily intake. If sodium levels trended downward, fluids were tightened to 1-1.2 L, or patients were brought in for further workup. The discharge packet included a 1.5-L cup so patients could track their intake.

Among 118 patients studied before the protocol was implemented in September 2015, 9 (7.6%) were readmitted for symptomatic hyponatremia within 30 days. Among 169 studied after the implementation of the fluid restriction protocol, just 4 (2.4%) were readmitted for hyponatremia (P = .044).

“What was surprising is that we did not have any readmissions for dehydration/hypernatremia. That was the biggest [concern] among physicians, that we are going to dry out these patients and they would come back severely dehydrated. We didn’t see that.” With the protocol’s success, “this is now the routine management that all our endocrinologist attendings use,” Dr. Deaver said.

At present, there are no widely accepted postop fluid management guidelines for transsphenoidal surgery, but some hospitals have taken similar steps, she said.

It was the fluid restriction, not the 7-day sodium check, that drove the results. Among the four readmissions after the protocol took effect, two patients had their sodium checked, and two did not because their sodium drop was so precipitous that they were back in the hospital before the week was out. Overall, only about 70% of patients got their sodium checked as instructed.

 

Fluid restriction isn’t easy for patients. “The last day before discharge, we try to coach them through it,” with tips about sucking on ice chips and other strategies; “anything really to help them through it,” Dr. Deaver said.

Readmitted patients were no different from others in terms of pituitary tumor subtype, tumor size, gender, and other factors. “We couldn’t find any predictors,” she said. There were a higher percentage of macroadenomas in the preimplementation patients (91.5% versus 81.7%), but they were otherwise similar to postimplementation patients.

Those with evidence of diabetes insipidus at discharge were excluded from the study.

The National Institutes of Health funded the study. The investigators did not have any disclosures.

[email protected]

SOURCE: Deaver KE et al. Endocrine Society 2018 annual meeting abstract SUN-572.

 

CHICAGO – A 70% drop in 30-day readmissions following transsphenoidal surgery was achieved at the University of Colorado, Aurora, after endocrinologists there restricted fluid for the first 2 weeks postop, according to a report at the Endocrine Society annual meeting.

The antidiuretic hormone (ADH) rebound following pituitary adenoma resection often leads to fluid retention, and potentially dangerous hyponatremia, in about 25% of patients. It’s the leading cause of readmission for this procedure, occurring in up to 15% of patients.

To counter the problem, endocrinology fellow Kelsi Deaver, MD, and her colleagues limited patients to 1.5 L of fluid for 2 weeks after discharge, with a serum sodium check at day 7. If the sodium level was normal, patients remained on 1.5 L until the 2-week postop visit. If levels trended upward – a sign of dehydration – restrictions were eased to 2 or even 3 L, which is about the normal daily intake. If sodium levels trended downward, fluids were tightened to 1-1.2 L, or patients were brought in for further workup. The discharge packet included a 1.5-L cup so patients could track their intake.

Among 118 patients studied before the protocol was implemented in September 2015, 9 (7.6%) were readmitted for symptomatic hyponatremia within 30 days. Among 169 studied after the implementation of the fluid restriction protocol, just 4 (2.4%) were readmitted for hyponatremia (P = .044).

“What was surprising is that we did not have any readmissions for dehydration/hypernatremia. That was the biggest [concern] among physicians, that we are going to dry out these patients and they would come back severely dehydrated. We didn’t see that.” With the protocol’s success, “this is now the routine management that all our endocrinologist attendings use,” Dr. Deaver said.

At present, there are no widely accepted postop fluid management guidelines for transsphenoidal surgery, but some hospitals have taken similar steps, she said.

It was the fluid restriction, not the 7-day sodium check, that drove the results. Among the four readmissions after the protocol took effect, two patients had their sodium checked, and two did not because their sodium drop was so precipitous that they were back in the hospital before the week was out. Overall, only about 70% of patients got their sodium checked as instructed.

 

Fluid restriction isn’t easy for patients. “The last day before discharge, we try to coach them through it,” with tips about sucking on ice chips and other strategies; “anything really to help them through it,” Dr. Deaver said.

Readmitted patients were no different from others in terms of pituitary tumor subtype, tumor size, gender, and other factors. “We couldn’t find any predictors,” she said. There were a higher percentage of macroadenomas in the preimplementation patients (91.5% versus 81.7%), but they were otherwise similar to postimplementation patients.

Those with evidence of diabetes insipidus at discharge were excluded from the study.

The National Institutes of Health funded the study. The investigators did not have any disclosures.

[email protected]

SOURCE: Deaver KE et al. Endocrine Society 2018 annual meeting abstract SUN-572.