[Pituitary tumor resection in a patient with SARS-CoV-2 (COVID-19) infection. A case report and suggested airway management guidelines]

Abstract

The 2020 pandemic caused by the novel coronavirus, COVID-19, had its headquarters in China. It causes Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and presents a broad spectrum of clinical manifestations, ranging from entirely asymptomatic through severe acute respiratory failure and death. Presuming a significant quantity of ventilator-dependent patients, several institutions strategically delayed elective surgeries. Particularly procedures performed involving the nasal mucosa, such as a transsphenoidal approach of the pituitary gland, considering the tremendous level of viral shedding. Nevertheless, critical cases demand expeditious resolution. Those situations are severe pituitary apoplexy, declining consciousness level, or risk of acute visual loss. This case presents a successful urgent perioperative management of a 47 year-old male COVID-19 positive patient who presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention.

Keywords: Airway management; Anestesia; Infecção por SARS‐CoV‐2 (COVID‐19); Pituitary tumor; SARS‐CoV‐2 infection (COVID‐19); Tumor pituitário.

Figura 1

(a e b) Tomografia computadorizada sem contraste. Cortes axial (a) e coronal (b) mostram predomínio de massa selar hiperdensa medindo 1,9 ×2,8 ×2,0 cm, ecêntrica à esquerda com extensão para a cisterna supraselar, pinçamento do quiasma ótimo esquerdo e deiscência bilateral das paredes do seio esfenoide posterior.

Figura 2

(a‐c) RM hipofisária com e sem contraste. (a) Massa selar sagital T1 com obscurecimento da haste hipofisária. (b e c) T2 coronal e axial‐T2 heterogêneo perifericamente isointenso centralmente, massa escura com realce diminuído na sela turca estendendo‐se para a cisterna supraselar com efeito de massa local. Elevação do quiasma óptico e da porção pré‐quiasmática à esquerda maior do que no nervo óptico direito. Achados compatíveis com macroadenoma hipofisário com deposição central de hemosiderina sugerindo hemorragia remota.

Figura 3

Campo plástico sobre o paciente durante a manipulação para assegurar a via aérea.

Figura 4

Ordem Donning (protocolo UMMC) para pacientes positivos para COVID‐19.

Figura 5

Ordem Doffing (protocolo UMMC) para pacientes positivos para COVID‐19. Higiene das mãos**: Desinfetante de mão antisséptico espuma para higiene das mãos.