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Diabetes insípida central, SIADH, Síndrome Perdedor de sal post resección de tumores selares

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DIC, SIADH, CSW, diabetes insípida central, SIADH, Síndrome perdedor de Sal, tumores de la región selar, hipernatremias, hiponatremias

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Diabetes insípida central, SIADH, Síndrome Perdedor de sal post resección de tumores selares

  1. 1. UNMSM DIABETES INSÍPIDA CENTRAL, SIADH Y SÍNDROME PERDEDOR DE SAL POST CIRUGÍA SELAR Curso de Neurocirugía Oncológica Dra. Nilia Abad UCI 13 B Neurocirugía Hospital Nacional Edgardo Rebagliati Martins – Marzo 2015
  2. 2. DEFINICION DE POLIURIA • > 2ml/kg/h • > 3L en 24h • >250 ml/hora
  3. 3. VARIABLES FISIOLÓGICAS
  4. 4. VARIABLES FISIOLÓGICAS
  5. 5. ASPECTOS EPIDEMIOLÓGICOS • Resección TE de tumores de la pituitaria alcanzan el 20% de las resecciones IC de tumores primarios.
  6. 6. EVALUACION POSTQUIRÚRGICA
  7. 7. POLIURIA EN EL POSTOPERATORIO
  8. 8. CAUSAS COMUNES DE POLIURIA EN EL POSTOPERATORIO • Fluidos • Diuréticos • Hiperglicemia
  9. 9. DIABETES INSIPIDA • Central: insuficiente secreción de Vasopresina (AVP) por el hipotálamo • Nefrogénica: Inadecuada respuesta a la AVP en los túbulos renales.
  10. 10. DIABETES INSÍPIDA CENTRAL • Hereditaria • Idiopática Injuria hipotalámica, neurohipofisiaria o del tracto hipotálamo – hipofisiario: • Manipulación quirúrgica • Neoplásica • Autoinmune • Trauma • Radiación • Infección • Isquemia/ hemorragia
  11. 11. DI Nefrogénica • Hipercalcemia • Fármacos • Enfermedades primarias del riñón
  12. 12. FISIOPATOLOGÍA
  13. 13. FISIOPATOLOGÍA
  14. 14. FISIOPATOLOGÍA
  15. 15. FISIOPATOLOGÍA
  16. 16. FISIOPATOLOGIA
  17. 17. EPIDEMIOLOGÍA • 0.5% a 25% - 30% en el postoperatorio • 20 – 30% DIC transitoria • 2 – 10% DIC permanente • 13.6% transitoria (Vía endoscópica) • 2.7% permanente (Vía endoscópica)
  18. 18. EPIDEMIOLOGÍA
  19. 19. EPIDEMIOLOGÍA
  20. 20. FACTORES DE RIESGO: VÍA ENDOSCÓPICA • Microadenoma • Craneofaringioma • Quiste de la bolsa de Rathke • Pérdida de LRC en el intraoperatorio • Na >145 meq/L • Incremento de Na más de 2.5 meq/L (Pre –postQx.) Pituitary (2013) 16:445–451
  21. 21. FACTORES DE RIESGO: VÍA ENDOSCÓPICA
  22. 22. FACTORES DE RIESGO: RESECCIÓN MICROQUIRÚRGICA TRANSNASAL • Microadenomas (DI transitoria) • Pérdida de LCR intraoperatoria (transitoria y persistente) • Craneofaringiomas (transitoria y persistente) • Quiste de la Bolsa de Rathke (transitoria y persistente).
  23. 23. PATRONES DE PRESENTACIÓN • Transitoria: más frecuente, 24 a 48h post cirugía, resolución en 3 a 5 días. • 6% después de la primera semana • Permanente (Daño hipotalámico o infundíbulo proximal) • Patrón trifásico menos frecuente: Poliuria – Antidiuresis – Poliuria.(1.1%) • Patrón bifásico (3.4%) Pituitary (2013) 16:445–451
  24. 24. RMN
  25. 25. PATRONES DE PRESENTACIÓN
  26. 26. PATRONES DE PRESENTACIÓN
  27. 27. CRITERIOS DIAGNÓSTICOS • Densidad urinaria < 1005 • Poliuria: volumen urinario > 300 ml/h por 3 horas consecutivas en ausencia de glucosuria. • Polidipsia • Na > 145 meq/L
  28. 28. DIAGNÓSTICO DIFERENCIAL
  29. 29. TRATAMIENTO • Fluidos: VO ó EV (Solución Salina Normal) • Desmopresina • Vida media: 3h • Efecto: 10h
  30. 30. TRATAMIENTO • Desmopresina (DDAVP) 0.1 mg VO (en dos a tres dosis) • DDAVP 1ug SC • DDAVP 10 a 40 ug intranasal (en dos dosis) • DDAVP 2 a 4 ug EV (en una o dos dosis)
  31. 31. TRATAMIENTO
  32. 32. TRATAMIENTO • Otras drogas: ▫ Carbamazepina ▫ Clorpropamida ▫ Hidroclorotiazida
  33. 33. HIPONATREMIA POSTQUIRÚRGICA • 9 % a 24% post cirugía de la pituitaria, pico en el séptimo día. • Causas: SIADH, sobreadministración de Desmopresina. • Descartar causas de pseudohiponatremia: hiperglicemia, hipotiroidismo, insuficiencia adrenal no tratada
  34. 34. PATRONES DE HIPONATREMIA POSTOPERATORIA
  35. 35. 165 Cirugías, 16% hiponatremias, 4to. Día postoperatorio, 19% sintomáticos
  36. 36. SECRECION INAPROPIADA DE HORMONA ANTIDIURÉTICA (SIADH) • 9% a 25% post cirugía de la pituitaria • Causas: ▫ Neoplasias (Cerebro, Pulmón) ▫ Infecciosas (Meningitis, abscesos cerebrales) ▫ TEC ▫ Dolor, emesis ▫ Fármacos: clorpromazina, morfina, ciclofosfamida
  37. 37. PATRÓN DE PRESENTACIÓN • Hiponatremia (Na < 135 meq/L) • Síntomas: cefalea, náuseas, vómitos, casos severos: confusión, convulsiones, estupor , coma. • Euvolemia o discreta hipervolemia • Función renal normal • Función adrenal normal
  38. 38. TRATAMIENTO • Restricción de fluidos • Solución hipertónica 3% (Si Na < 120 - 125 meq/L ) ó la hiponatremia es sintomática. • Vaptanes: ▫ Conivaptan: 20 mg en bolo, luego 20 a 40 mg /día en infusión por 4 días ▫ Incrementa >6 meq/L en 13 h.
  39. 39. SÍNDROME PERDEDOR DE SAL (CSW) • Término acuñado en 1954: Cort • **Hemorragia subaracnoidea • Meningitis • Carcinomatosis meníngea • Tumores del SNC • Injuria aguda del SNC • Post cirugía
  40. 40. CSW: FISIOPATOLOGIA
  41. 41. CSW- SIADH
  42. 42. SIADH - CSW
  43. 43. HIPONATREMIA
  44. 44. HIPONATREMIA
  45. 45. TRATAMIENTO • Na < 125 meq/L : 4 meq en las primeras 2 horas • No más de 10 a 12 meq/L en 24h • No más de 18 meq/L en 48h • SSH 3% infusión continua si Na < 120 meq/L • SSN ó SSH 1.5% + fludrocortisona: 0.1 a 0.2 mg bid
  46. 46. PUNTOS CLAVE

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