The hypophysectomy patient in the OR

The hypophysectomy patient in the OR

Brenda C Mauldin, RN The hypophysectomy patient in the OR Because transsphenoidal hypophysectomy can be done in less than two hours, and the procedu...

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Brenda C Mauldin, RN

The hypophysectomy patient in the OR

Because transsphenoidal hypophysectomy can be done in less than two hours, and the procedure is far less stressful than frontal craniotomy, patients who were previously considered poor risks are now candidates for the procedures. Hypophysectomy is done primarily for its palliative effects on metastatic breast or prostate cancer. The removal of the pituitary gland is probably not the first surgical procedure for these patients. They may also have been treated with chemotherapy or radiation or both. Consequently, the operating room nurse is caring for a patient with seriously compromised major body systems. Patients may come to the OR frightened but hopeful that the surgery will relieve their pain and perhaps bring a remission in their disease.

Brenda C Mauldin, RN, is staff nurse I1 in the operating rooms at Emory University Hospital, Atlanta. She is a graduate of DeKalb Community College, Clarkston, Ga.

Pain relief from the procedure is dramatic, occurring 24 to 36 hours following surgery. Remissions occur in approximately 45% of patients with breast cancer and in 35% of prostatic cancer patients, with some studies reporting results as high as 60% to 75%. Removing the pituitary gland and thus its hormones brings about the pain relief. Gonadotropins, growth hormone, and/or prolactin are thought to be the influential substances. The approach in open transsphenoida1 hypophysectomy is through an upper gingival incision. The nasal septum and anterior wall of the sphenoid sinus are removed, allowing the surgeon to use an operating microscope to remove the pituitary gland. The microscope is set up by the circulating nurse and should be checked before each use. She must know how to use the instrument and be familiar with its parts. A check-list may be helpful. 1 Connect all power lines, checking the light source. Have extra bulbs available. 2. Position the microscope for the comfort of the surgeon. 3. Connect all photographic equipment properly. 4. Attach optical elements, making sure they are clean and dust-free. 5. Do a preliminary focusing of the microscope. 6. Leave the microscope in a position so that it can be easily draped.2

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X-rays and computed tomography (CT) scans of the patient should be put on the view box. If fluoroscopy is to be used, the circulating nurse should assist the x-ray technicians with positioning the equipment. Electrosurgical units, including a bipolar unit, are connected and checked. The units are placed so they can be easily connected once the procedure begins. Preparation should also be made to handle the pituitary gland once it is excised, if the surgeon indicates any special studies are to be done. Formalin 10% is primarily used otherwise. The scrub nurse sets up her table and Mayo stands of sterile supplies and instruments. Standard drapes are used for this procedure. If fluoroscopy is used, additional drapes may be necessary to cover this equipment adequately. A special microscope drape completes the draping setup. Care and preparation of the delicate microsurgical instruments is delegated to the scrub nurse. A standard set of microsurgical instruments costs approximately $7,000, so proper care and handling is important. Also needed is a separate set of dissecting instruments for taking a fat graft from the abdomen. The graR is used in closing the transsphenoidal wound. Draping the irregularly shaped microscope requires skill and practice to maintain the sterility of the drape. The circulating nurse can assist the scrub nurse by working from the outside inner edges of the drape to pull it over the microscope. Before the patient arrives i n the operating room, the nurse reviews his chart to check for allergies, physical limitations, presence of reports for all preoperative laboratory studies, and the preoperative nurses’ checklist. She double checks to be sure the patient’s dentures, contact lenses, and jewelry have been removed. She also confirms the patient’s identity on the arm band.

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Fig 1. In the supine position, care should be taken to protect skin in the occipital area of the head, the shoulder blades, elbows, coccyx, and back of the heels.

In the operating room, the circulating nurse should be especially sensitive to the patient’s needs during the brief time before anesthesia induction. Greeting the patient, introducing herself, and touching him on the shoulder or hand may help lessen his anxieties. Because cancer patients may be debilitated, they often need added help moving to the OR bed, and they should be cautioned to move slowly. When the patient is as comfortable as possible, the nurse offers him a blanket and stands by until intubation is completed.

AORN Journal, February 1981, Vol33, No 2

A f t e r t h e patient has been intubated, h e i s ready t o be positioned. The supine position i s used, with the head positioned t o allow easy access t o t h e upper gingival approach. Good surgical positioning maintains proper body alignment and circulation and avoids pressure points. Care should be t a k e n t o protect s k i n areas particularly susceptible t o s k i n breakdown in t h i s position-the occipital area o f t h e head, t h e shoulder blades, elbows, coccyx area, and t h e back o f t h e heels (Fig lh3 Properly placed sheets and pillows help maintain s k i n integrity. A f t e r positioning, t h e patient’s s k i n i s prepared, and h e i s draped. During t h e surgical procedure, t h e circulating nurse completes the operative records, including a nurse’s note. This documentation o f care given during surgery assists t h e unit nurse in providing continuing care. A f t e r t h e hypophysectomy, t h e pat i e n t goes t o t h e recovery room o r t h e special care unit with two soft rubber endonasal airways, w h i c h a l l o w f o r reattachment o f t h e nasal mucosa and breathing comfort. The microscope i s cleaned and dismantled for storage. The delicate mic r o s u r g i c a l i n s t r u m e n t s a r e hand washed and stored in a special protective case for resterilization. Because t h e microscope and instruments are so f i n e and expensive, t h e nurse assumes responsibility for being sure they receive t h e proper care and handlingt o prepare 0 t h e m for t h e n e x t case. Notes 1. George TTindall, William F Collins, “Hypophysectomy, current status,” in Clinical Managementof Pituitary Disorders (New York: Raven Press, 1979) 389-496. 2. May McDonald, Linda DuKore, “The operating microscope and the neurosurgical nurse,” Point of View 15 (April 1978) 6-7. 3. Charlene Gladney Foster et al, “Effects of surgical positioning,”AORN Journal 30 (August 1979) 219-232.

Deaths during exercise due to prior disease The tales of middle-aged men who die during strenuous exercise are frequent enough to offer many individuals an excuse for avoiding exercise altogether. But those men who die on the tennis court or the jogging track almost invariably are individuals who already had serious heart disease, says a report in the Oct 17 Journal of the American Medical Association. The Institute for Aerobics Research, an exercise center in Dallas, kept records for more than five years on almost 3,000 adults in an effort to determine whether exercise causes heart attacks. There were only two heart attacks during exercise and no deaths during the study, reports Larry W Gibbons, MD. Both men survived and were again exercising regularly. “It appears that middle-aged men who die suddenly or have cardiac events in association with exercise usually are individuals with severe coronary disease,” Dr Gibbons says. The Dallas physician cites other studies that found that in 63 cases of sudden death associated with physical exercise, in no instance could death be regarded as due to the effects of extreme exertion on a previously healthy heart. The combination of exercise and disease carries the major risk. Exercise places an additional stress on an already susceptible heart. The conclusion is that there is a small, but not negligible, acute risk of heart attack for adults participating in vigorous exercise. But factors such as heart disease, competition, regularity of exercise, and smoking may increase or decrease the risk.

Two Journal issues published in February Two issues of the AORN Journal will be published in February. One issue will be the regular February Journal. The other will be the pre-CongressJournal, containing the educational program and other Congress information.

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