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CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 75-77

Anesthetic challenges in a case of Sheehan's syndrome posted for open reduction and internal fixation and nailing following fracture femur


Department of Anaesthesia, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission10-Oct-2021
Date of Decision08-Nov-2021
Date of Acceptance17-Jan-2022
Date of Web Publication8-Jul-2022

Correspondence Address:
Dr. Abinaya Ramachandran
Department of Anesthesia, Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_78_21

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  Abstract 


Sheehan's syndrome is postpartum hypopituitarism caused by necrosis of the pituitary gland due to severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with Sheehan's syndrome have varying degrees of pituitary hormone deficiency. There is increased sensitivity to barbiturates and opiates in patients with Sheehan's syndrome. They are more prone to hypotension, hypoxia, and hypothermia which must be addressed intraoperatively. Herein, we report successful anesthetic management of a patient with Sheehan's syndrome with distal third femoral shaft fracture for fixation who had numerous hormonal and electrolyte abnormalities. This case report emphasizes the importance of meticulous preanesthetic assessment, optimization, and perioperative management of patients with Sheehan's syndrome for successful management of the case.

Keywords: Electrolyte imbalance, hypopituitarism, postpartum hemorrhage, Sheehan's syndrome


How to cite this article:
Ramachandran A, Palanisamy N, Johny PT, Ranjan R V. Anesthetic challenges in a case of Sheehan's syndrome posted for open reduction and internal fixation and nailing following fracture femur. J Curr Res Sci Med 2022;8:75-7

How to cite this URL:
Ramachandran A, Palanisamy N, Johny PT, Ranjan R V. Anesthetic challenges in a case of Sheehan's syndrome posted for open reduction and internal fixation and nailing following fracture femur. J Curr Res Sci Med [serial online] 2022 [cited 2022 Aug 19];8:75-7. Available from: https://www.jcrsmed.org/text.asp?2022/8/1/75/350141




  Introduction Top


Sheehan's syndrome is caused by ischemic necrosis of the pituitary gland following hypoperfusion to the pituitary gland. It was described in 1937 by the British pathologist Harold Leeming Sheehan.[1] The prevalence is around 3.2% in women <40 years of age and is relatively common in developing countries.[2] The clinical features are mainly due to the reduced hormone levels. The diagnosis is made with the help of a suggestive obstetric history, clinical manifestations, laboratory findings of reduced hormone levels, and pertinent radiological features. The treatment is to replace the patient with deficient hormones and prevent the complications associated with it. We present the anesthetic management of a patient with Sheehan's syndrome posted for open reduction and internal fixation under regional anesthesia due to the rarity of its presentation. Consent for use of clinical data for the academic purpose was obtained from the patient.


  Case Report Top


A 55-year-old female was admitted to our hospital with two months old closed fracture of the distal third of the shaft of the femur. The patient was diagnosed with Sheehan's syndrome 23 years ago. There was a history of postpartum hemorrhage following the birth of her second child which was treated with blood transfusion and vasopressors in the intensive care unit. The patient also had lactation failure and is nonmenstruating since then. She was on tablet thyroxine 50 μg once a day in the morning for hypothyroidism and tablet prednisolone 5 mg OD for hypocortisolemia for more than 15 years. The patient looked clinically pale and had dry skin. Her heart rate was 64/min and regular, blood pressure was 120/80 mm of Hg in the supine position, saturation in room air was 100%, the respiratory rate was 14/min. All blood investigations were done and are shown in [Table 1]. Magnetic resonance imaging brain was taken and the image showed an empty sella turcica [Figure 1]. On further evaluation by the endocrinologist, she was found to have hypocalcemia and hyponatremia. She was started on oral calcium supplements and was started on 3% hypertonic saline intravenously. With adequate preoperative preparation, the patient was planned for the fracture fixation under the combined spinal-epidural technique.
Figure 1: T1W sag and T2W cor magnetic resonance images shows empty sella with thinned out pituitary gland along the floor of the sella (marked by yellow arrow)

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Table 1: Investigations at the time of admission

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After obtaining informed written consent from the patient, the patient was shifted to the operating room, 2 large-bore intravenous cannulas were placed. The baseline vitals were HR: 72/min, BP: 110/60mm Hg, SPO2: 100%. A 20G IV cannula was secured on the left hand for invasive arterial blood pressure monitoring. Replacement dose of injection hydrocortisone 100 mg IV stat was given at the beginning of the procedure.

With the patient in sitting position, under strict aseptic precautions using an 18G combined spinal-epidural needle set, at L3–L4 intervertebral space, an epidural catheter was fixed at 9 cm from the skin level and 2.2 ml of 0.5% hyperbaric bupivacaine and 25 mcg of injection fentanyl was administered intrathecally. The patient had adequate motor blockade to T10 level. Forced air warmer and warm intravenous fluids were administered to prevent the fall in core body temperature. Intraoperative hypotension was managed with injetion injection noradrenaline titrated according titrated according to hemodynamics. There were about 800 ml of blood loss and one unit of the packed cell was transfused intraoperatively. Normothermia was maintained throughout and hourly blood sugar and urine output were monitored and maintained. Hypertonic saline 3% was started at 15 ml/h infusion because of persistent hyponatremia. The surgical procedure was uneventful and the patient was shifted to a high dependency unit for postoperative monitoring and observation. Postoperative pain relief was managed with epidural infusions of 6 ml/h of 0.0625% bupivacaine along with 1 mcg/ml of injetion fentanyl for 48 h. Injection hydrocortisone 50 mg IV sixth hourly was given on the first postoperative day. Intravenous steroids were tapered according to the endocrinologist's advice and subsequently converted to oral steroids.


  Discussion Top


Postpartum pituitary necrosis is caused due to massive obstetric hemorrhage either in the intrapartum or postpartum period leading to severe hypotension and shock. It presents with a broad spectrum of symptoms such as dry skin, loss of eyebrows and pubic hair, lower pulse rate, unstable blood pressure, amenorrhea, failure to lactate, secondary hypothyroidism, diabetes insipidus, growth hormone deficiency to major life-threatening adrenal insufficiency.[1],[3] However, the diagnosis is often delayed because of the progressive and diverse clinical presentation at varying period. There are several coagulation abnormalities such as prolongation of activated partial thromboplastin time, elevated levels of fibrin degradation products, and D-Dimer.[4]

Patients also present with different types of electrolyte abnormalities with hyponatremia being the most common one to about 33% to 69%.[5],[6] Our patient also had persistent hyponatremia despite correction with hypertonic saline.

Low levels of cortisol, thyroid hormone, growth hormone, and prolactin may confirm the diagnosis along with definitive radiological signs. Timely diagnosis and prompt initiation of hormone replacement therapy are essential to reduce morbidity and the associated mortality.

There is also increased sensitivity to barbiturates and opioids which may delay the recovery of the patient from general anesthesia. Supporting this, there is a case report of a 35-year-old female scheduled for laparoscopic appendectomy who had a delayed recovery following general anesthesia and was mechanically ventilated for 7 days. The diagnosis of Sheehan'ssyndrome was made retrospectively by integrating the findings of reduced hormone levels and dyselectrolytemia with the patient's history of severe postpartum hemorrhage 4 years ago.[7]

Regional anesthesia techniques are beneficial and relatively safer if the fluid status is replaced adequately. A 28-year-old female with twin pregnancies with Sheehan's syndrome successfully underwent elective cesarean section under spinal anesthesia avoiding the risks of general anesthesia.[8] Reviewing all these factors, we also chose regional anesthesia over GA for our patient.


  Conclusion Top


Sheehan's Syndrome is an infrequent complication. The anesthetic concerns include the pre-existing fluid deficit, electrolyte imbalances, perioperative hypotension, hypoglycemia, neuropsychiatric dysfunctions, decrease in core body temperature, coagulation abnormalities, hypoxia, less requirement of anesthetic agents, delayed recovery from general anesthetic, steroid and stress management, life-threatening adrenal insufficiency, and circulatory collapse. With careful preoperative evaluation, meticulous planning, sufficient patient preparation, and increased vigilance, the patient had an uneventful surgery and perioperative course.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/ have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tessnow AH, Wilson JD. The changing face of sheehan's syndrome. Am J Med Sci 2010;340:402-6.  Back to cited text no. 1
    
2.
Wilson AM. Anaesthesia for sheehan's syndrome. A case report. Br J Anaesth 1968;40:996-8.  Back to cited text no. 2
    
3.
Zargar AH, Singh B, Laway BA, Masoodi SR, Wani AI, Bashir MI. Epidemiologic aspects of postpartum pituitary hypofunction (Sheehan's syndrome). Fertil Steril 2005;84:523-8.  Back to cited text no. 3
    
4.
Shivaprasad C. Sheehan's syndrome: Newer advances. Indian J Endocrinol Metab 2011;15:S203-7.  Back to cited text no. 4
    
5.
Huang YY, Ting MK, Hsu BR, Tsai JS. Demonstration of reserved anterior pituitary function among patients with amenorrhea after postpartum hemorrhage. Gynecol Endocrinol 2000;14:99-104.  Back to cited text no. 5
    
6.
Bunch TJ, Dunn WF, Basu A, Gosman RI. Hyponatremia and hypoglycemia in acute Sheehan's syndrome. Gynecol Endocrinol 2002;16:419-23.  Back to cited text no. 6
    
7.
Choudhary G, Soni S, Mohammed S. Sheehan's syndrome: A rare cause of delayed recovery after anesthesia. J Obstet Anaesth Crit Care 2020;10:58-60.  Back to cited text no. 7
  [Full text]  
8.
Arora G, Sahni N. Anesthetic management of a patient with sheehan's syndrome and twin pregnancy while undergoing a cesarean section. J Postgrad Med 2020;66:51-3.  Back to cited text no. 8
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