Describes the anaesthetic management of pituitary surgeries

1. PITUITARY GLAND
DISORDERS AND
ANESTHETIC
MANAGEMENT
PRESENTER : DR UNNIKRISHNAN P.
COORDINATOR : DR MAYA
MODERATORS: DR JAYAKUMAR
DR RAVI

2. .

3. WE HAVE TO
• optimize the patient undergoing the surgery

4. WE HAVE TO
• take care of the patient perioperatively

5. ANATOMY

6. .

7. .
SOMATOTROPES 50% GH
MAMMOTROPES 25% PROLACTIN
CORTICOTROPES 15% ACTH
THYROTROPES 10% TSH
GONADOTROPES 10% LH & FSH
NULL CELLS INERT

8. ANATOMY

9. ANATOMY

10. CONTROL OF PITUITARY
FUNCTION

11. ↑ACTH
CORTICOTROPIN RELEASING
HORMONE .
THYROTROPIN RELEASING HORMONE ↑TSH & PROLACTIN
GROWTH HORMONE RELEASING ↑GH
HORMONE
GROWTH HORMONE INHIBITING ↓GH &TSH
HORMONE
[SOMATOSTATIN]
GONADOTROPIN RELEASING ↑LH & FSH
HORMONE
PROLACTING INHIBITING HORMONE ↓PROLACTIN

12. DISORDERS OF PITUITARY
FUNCTION

13. HYPOPITUITARISM
AETIOLOGY
DEVELOPMENTAL: KALLMANN SYNDROME
TRAUMATIC: SURGERY RADIATION HEAD INJURY
NEOPLASM : PITUITARY ADENOMA CRANIOPHARYNGIOMA
RATHKE’S CYST METASTASIS
INFILTRATORY / INFLAMMATORY : SARCOIDOSIS
VASCULAR : PITUITARY APOPLEXY SHEEHANS SYNDROME
INFECTION

14. CLINICAL FEATURES

15. CLINICAL FEATURES

16. LAB DIAGNOSIS
• PRINCIPLE:
• DEMONSTRATE LOW LEVELS OF
TROPIC HORMONES IN THE SETTING
OF LOW TARGET HORMONE LEVELS..

17. LAB DIAGNOSIS
HORMONE TESTS
GROWTH HORMONE INSULIN TOLERANCE TEST, GHRH
TEST, L-DOPA TEST
PROLACTIN TRH TEST
ACTH INSULIN TOLERANCE TEST
METYRAPONE TEST , ACTH
STIMULATION TEST
LH/FSH GnRH TEST
COMBINED ANTERIOR
PITUITARY TEST

18. TREATMENT
DEFICIENCY REPLACEMENT
HYDROCORTISONE 10-20 MG AM 5-
10 MG PM
TSH L-THYROXINE 0.075-0.15 MG DAILY
FSH / LH males TESTOSTERONE ENANTHATE 200MG
IM EVERY 2 WEEKS
females CONJUGATED OESTROGEN 0.65-
1.25MG QD X 25 DAYS
GH SOMATOTROPIN 0.1-1.25 MG SC QD
VASOPRESSIN INTRANASAL VASOPRESSIN 5-20µG
BD

19. CURRE <10 MG ASSUME ADDITIONAL STEROID COVER NOT
NTLY QD NORMAL HPA REQUIRED
TAKIN [PREDNIS AXIS
G
STERO STEROID REPLACEMENT
OLONE]
ID
>10MG QD MINOR 25MG HYDROCORT. AT INDUCTION
SURGERY
MODERATE USUAL PREOP.DOSE + 25MG
SURGERY HYDROCORT. AT INDUCTION +
100MG/ DAY FOR 24 HRS
MAJOR USUAL PREOPERATIVE STEROID +
SURGERY 25 MG HYDROCORTISONE AT
INDUCTION +100MG/DAY X 48-72 H
HIGH GIVE SAME
DOSE
STOPPE < 3 MS TREAT AS IF ON
D STEROIDS
>3 MS NO PERIOP.
STEROID

20. STEROID
SUPPLIMENTATION[Miller/7/e]
SURGERY HYDROCORTISONE
MAJOR 200 MG/DAY PER 70 KG
MINOR 100 MG/DAY PER 70 KG
DECREASE THE DOSE BY
25%/DAY UNTIL ORAL FEEDS
START, THEN USUAL
MAINTENANCE DOSE

21. PITUITARY TUMOURS

22. TYPES
• ADENOMAS ARE THE COMMONEST
CAUSE OF ABNORMAL ENDOCRINE
PITUITARY FUNCTION
• 10-15% OF ALL INTRACRANIAL TUMORS
• MOST ARE BENIGN; 50% PROLACTINOMAs
CELL TYPE HORMONE SYNDROME
LACTOTROPE PROLACTIN HYPOGONADISM
GALACTORRHOEA
GONADOTROPE FSH / LH HYPOGONADISM
SOMATOTROPE GH ACROMEGALY
GIGANTISM
CORTICOTROPE ACTH CUSHINGS DISEASE

23. EFFECTS
IMPACTED STRUCTURE CLINICAL IMPACT
PITUITARY HORMONAL IMBALANCE
OPTIC CHIASMA VISUAL FIELD ABNORMALITIES
OPTIC /OCULOMOTOR
HYPOTHALAMUS TEMPERATURE DYSREGULATION
APPETITE/THIRST DISORDERS
OBESITY DIABETES INSIPIDUS
CAVERNOUS SINUS OPHTHALMOPLEGIA
FRONTAL LOBE PERSONALITY DISORDER
BRAIN HEADACHE HYDROCEPHALUS
EPILEPSY

24. EVALUATION AND
DIAGNOSIS IN GENERAL
BASAL PROLACTIN LEVELS, TFT
HIGH QUALITY MRI
OPHTHALMIC EVALUATION NECESSARY
TREATMENT : DEPENDS ON TUMOR
SURGERY /RADIATION/MEDICAL

25. Craniopharyngiomas
• are benign, suprasellar cystic masses that
present with headaches, visual field deficits,
and variable degrees of hypopituitarism.
They are derived from Rathke's pouch and
arise near the pituitary stalk

26. RATHKE’S CYSTS
• Developmental failure of Rathke's pouch
obliteration may lead to Rathke's cysts
• compressive symptoms, diabetes insipidus,
and hyperprolactinemia due to stalk
compression

27. ACTH SECRETING TUMORS
CLINICAL CONDITION RESULTING
FROM INCREASED ACTH SECRETION
BY PITUITARY ADENOMA-”CUSHINGS
DISEASE”
MOST ARE MICROADENOMAS
MORE IN WOMEN
EARLY DIAGNOSIS

28. ACTH SECRETING TUMORS
MOONS FACE BUFFALO OBESITY
PROXIMAL MYOPATHY OSTEOPOROSIS
VERTEBRAL COLLAPSE
STRIAE HIRSUITISM ACNE
DIABETES
HYPERTENSION LVH
HYPERNATREMIA HYPOKALEMIA ALKALOSIS
OSAS
GERD
RENAL STONE MENTAL DISTURBANCE

29. ACTH SECRETING TUMORS
DIFFERENCE FROM ECTOPIC ACTH
PRODUCING TUMORS: SLOW ONSET,
HYPOKALEMIA LESS INTENSE,HIGH
DOSE STEROID CAN SUPPRESS
CORTISOL SECRETION UNLIKE AS IN
ECTOPIC PRODUCTION OF CORTISOL

30. ACTH SECRETING TUMORS
DIAGNOSIS
URINARY FREE CORTISOL
HIGH DOSE DEXAMETHASONE
SUPPRESSION TEST [2MG Q6H X 48h]
CRH TEST EXAGGERATED RESPONSE
ACTH  UNDETECTABLE ADRENAL TUMOR
10-100 ng/L PITUITARY DEPENDENT
>200 ng/L ECTOPIC ACTH SECRETION

31. ACTH SECRETING TUMORS
TREATMENT
SURGERY-CURATIVE IN <80%
PRETREATMENT WITH
METYRAPONE/BETACONAZOLE
REVERSES EFFECTS OF EXCESS
CORTISOL AND DECREASE
PERIOPERATIVE MORBIDITY

32. ACTH SECRETING TUMORS
PERIOPERATIVE CONCERNS
BLEED EASILY
TENDS TO HAVE HIGH CVP
PROPER Rx OF HTN AND DM
ENSURE NORMAL INTRAVASCULAR
VOLUME & ELECTROLYTES
OSTEOPENIAHIGH CHANCE OF
FRACTURES CAREFUL POSITIONING
IMMUNOSUPPRESSION / INFECTION

33. PROLACTINOMAS
>50% OF FUNCTIONING TUMOURS
MAJORITY ARE MICROADENOMA
MORE IN WOMEN [90%]
2º AMENORRHOEA,
INFERTILITY,GALACTORRHOEA
MACROADENOMA MORE IN MEN
PRESSURE EFFECTS MAIN SYMPTOM
PROLACTIN >400 mU/ L

34. PROLACTINOMAS:Rx
M E D I C A L
FIRST LINE;CURATIVE IN UPTO 95%
CABERGOLINE [LONG ACTING]
BROMOCRIPTINE [SHORT ACTING]
S U R G I C A L
ONLY IF DOPAMINE
RESISTANCE/SIDE EFFECTS
INVASIVE ADENOMA,
COMPROMISING VISION

35. ACROMEGALY

36. GH GH GH everywhere…
GH hyper secretion from a pituitary
macroadenoma
If occurs before epiphyseal fusion
Gigantism
After epiphyseal fusionAcromegaly

37. Clinical Features
FACE INCREASE IN SIZE OF SKULL AND
SUPRAORBITAL RIDGES
ENLARGED MANDIBLE *large blade*
INCREASE IN SPACING BETWEEN TEETH
MALOCCLUSSION
HANDS&FEET SPADE SHAPED CARPAL TUNNEL SYNDROME
INCREASED HAND AND FOOT SIZE *SpO2 probe*
MOUTH&TONGUE MACROGLOSSIA ,THICKENED PERI EPIGLOTTIC
FOLDS AND LARYNGEAL SOFT TISSUES SMALL
LARYNGEAL APERTURE *difficult laryngoscopy*
OBSTRUCTIVE SLEEP APNOEA
SOFT TISSUE THICK SKIN DOUGH LIKE FEEL TO PALM
SKELETAL VERTEBRAL ENLARGEMENT KYPHOSIS
OSTEOPOROSIS
CVS HYPERTENSION CARDIOMEGALY
LV DYSFUNCTION
ENDOCRINE IMPAIRED GLUCOSE TOLERANCE, DIABETES
OTHERS ARTHROPATHY, PROXIMAL MYOPATHY
THYROID ENLARGEMENT *tracheal compression*
RLN PALSY

38. DIAGNOSIS
24 H GROWTH HORMONE LEVELS
ELEVATED S.IGF LEVELS
ORAL GLUCOSE TOLERANCE TEST
FAILURE OF GROWTH HORMONE SUPPRESSION TO
TO <1µG/L WITHIN 1-2 HRS OF AN ORAL GLUCOSE
LOAD 75G

39. TREATMENT
SURGICAL RESECTION [cure rate upto 70%]
Soft tissue swelling improves
GH level returns to normal
IGF-1 levels normalised
Complication : hypopituitarism ,recurrence

40. TREATMENT
MEDICAL
Dopamine agonists: Bromocriptine, Cabergoline
Somatostatin Analogues: Octreotide ,Lanreotide
preoperative shrinkage
GH receptor antagonist : Pegvisomant

41. PRE ANESTHETIC CHECK-UP
DETAILED & CAREFUL AIRWAY ASSESSMENT
INDIRECT LARYNGOSCOPY
OSAS : SNORING , DAYTIME SLEEPINESS
CENTRAL RESPIRATORY DEPRESSION
PERIOPERATIVE AIRWAY COMPROMISE : RISK OF
DEATH IS 3 FOLD HIGH
HYPERTENSION : ARRHYTHMIAS,CCF CHECK
ANTIHYPERTENSIVES
LV DYSFUNCTION
DIABETES MELLITUS [IN 50%]
VISUAL FUNCTION
RAISED ICP
HORMONAL FUNCTION: CHECK RECENT REPORTS /
OPTIMIZE

42. SURGERY
APPROACHES
TRANS SPHENOIDAL
TRANS ETHMOIDAL
TRANS CRANIAL

43. WHY TRANSSPHENOIDAL
APPROACH
RAPID ACCESS
LESS TRAUMA,
LESS BLEEDING
LESS
COMPLICATIONS

44. OTHER APPROACHES
TRANS FRONTAL : IF SUPRASELLAR
EXTENSION / POSTOP SEIZURES
PTERIONAL CRANIOTOMY
TRANSCRANIAL : IF SMALL
SPHENOID;S/E HIGH CHANCE OF
HYPOPITUITARISM

45. REMEMBER TO GIVE..
HYDROCORTISONE 100 MG
•.
PROPHYLACTIC ANTIBIOTICS
•.

46. ACCESSING THE AIRWAY…
BAG & MASK VENTILATION: MAY NEED
OROPHARYNGEAL AIRWAY
4 GRADES OF AIRWAY INVOLVEMENT
GRADE 3 & 4 : TRACHEOSTOMY
FIBREOPTIC LARYNGOSCOPY
GRADE 1 NO SIGNIFICANT INVOLVEMENT
GRADE 2 NASAL & PHARYNGEAL MUCOSA HYPERTROPHY
GRADE 3 GLOTTIC STENOSIS / VOCAL CORD PARESIS
GRADE 4 2&3 i.e. GLOTTIC & SOFT TISSUE INVOLVEMENT

47. SO BE READY WITH……
• LARGER FACE MASKS
• LONG BLADED LARYNGOSCOPS
• ILMA
• FIBREOPTIC LARYNGOSCOPE IF
AVAILABLE
• TRACHEOSTOMY SET
• N.B.NASAL INTUBATION HAZARDOUS IF
PREVIOUS TRANSSPHENOIDAL SURGERY
HAS BEEN DONE

48. POST INTUBATION
POSITION TUBE TO ALLOW ACCESS TO THE INCISION SITE
PACK THE MOUTH AND POSTERIOR PHARYNX
↓LARYNGOSPASM ↓PONV
LUMBAR DRAIN IF SUPRASELLAR EXTENSION
SUPRASELLAR PART PROLAPSES
10 ML ALIQUOTES OF .9% SALINE
INTO FIELD

49. TRANSSPHENOIDAL ROUTE
ENT SURGEON WILL ASSIST NEUROSURGEON
XYLOMETAZOLINE SAFER FOR PREPARATION OF NASAL MUCOSA
SUPINE
MODERATE DEGREE HEAD UP / CAUTION:IF >15º
HEAD SLIGHTLY TURNED {CAUTION : NECK VEINS ? OBSTRUCTION}
SURGEON BEHIND THE HEAD OR TO THE RIGHT OR LEFT
ETT & BAINS CIRCUIT AWAY FROM FIELD
C-ARM : WEAR LED APRON

50. .
• .

51. .

52. INTRAOPERATIVE PERIOD

53. EFFECT OF AGENTS ON SECRETION OF HORMONES NOT A BIG CONCERN
.
↑ ICP : ? TIVA BETTER ? AVOID NITROUS OXIDE
SHORT ACTING AGENTS HASTEN RECOVERY AT END { PROPOFOL,
SEVOFLURANE ETC}
VENTILATE TO NORMOCAPNOEA
PERIODS OF INTENSE STIMULATION : SHORT ACTING OPIOID
PATIENT SHOULD NOT WAKE UP WITH PAIN ? IV MORPHINE 20’ BEFORE END
B/L MAXILLARY NERVE BLOCK PREVENT HYPERTENSIVE RESPONSE DURING
GA
EXAGGERATED RESPONSE TO EPINEPHRINE [ WITHOUT HALOTHANE]
TEMPERATURE DYSREGULATION
HYPOGLYCEMIA
ABNORMAL ENDOCRINE FUNCTION
CHANCE OF CAROTID ARTERY INJURY

54. .

55. .

56. MONITORS

57. COMPLICATIONS
TRANS TRANS CRANIAL
SPHENOIDAL
INJURY TO FRONTAL LOBE ISCHEMIC
CAROTID DAMAGE
INJURY TO INJURY TO OPTIC CHIASMA
PONS POST OP SEIZURES
[SUBFRONTAL]
ANOSMIA

58. EXTUBATION
RAPID & SMOOTH EMERGENCE NEEDED
FOR NEUROLOGICAL ASSESSMENT
SUCTION UNDER DIRECT VISION
REMOVE THROAT PACK ; BUT DON’T
DISLODGE NASAL PACKS & STENTS
RETURN OF RESPIRATION,LARYNGEAL
REFLEXES
OBEYING TO VERBAL COMMANDS
EXTUBATION

59. Postoperative concerns….
AIRWAY
BLOOD IN ORO AND NASOPHARYNX
NASAL PACKS
PREDISPOSITION TO AIRWAY
OBSTRUCTION
NASAL CPAP CANT BE APPLIED
NARCOTICS WITH CAUTION

60. Post operative concerns…
ANALGESIA
PAIN : TRANSSPHENOIDAL-MODERATE
TRANSCRANIAL-MORE INTENSE
NASAL PACK-DISTRESSING
CODEINE
MORPHINE i.m.
MORPHINE PCA

61. Post operative concerns..
ENDOCRINE MANAGEMENT
HYDROCORTISONE 50-50,25-25,20-10[6pm]
Prolactinoma :few days / Cushing's :few months
ENDOCRINOLOGY REVIEW

62. POSTOPERATIVE
COMPLICATIONS
DIABETES INSIPIDUS
SUSPECT IF URINE O/P >2mL/Kg/h &
S.Na >143 mmol/L
POLYURIA,THIRST
SEND PLASMA OSMOLARITY
[>295mosm/Kg] AND URINE
OSMOLARITY [<300 mosm/Kg]

63. POSTOPERATIVE
COMPLICATIONS:D.I.
IF AWAKE AND NORMAL THIRST: FLUIDS
COMA/THIRST MECHANISM
ABOLISHED/VERY HIGH URINE VOLUME
DESMOPRESSIN ACETATE [DDAVP]
PROBLEM:HYPONATREMIA
USUALLY RESOLVES IN FEW DAYS

64. POSTOPERATIVE
COMPLICATIONS
HYPONATREMIA
CAUSES : DDAVP Rx, SIADH
MONITOR S.ELECTROLYTES
FLUID RESTRICTION
USUALLY RESOLVE WITHIN 10 DAYS
NATRIURESIS+DIURESIS  CEREBRAL
SALT WASTING SYNDROME
DD: SIADH

65. POSTOPERATIVE
COMPLICATIONS
SIADH: WATER RETENTION Rx :
WATER RESTRICTION
CSW  Rx : HYPERTONIC SALINE

66. POSTERIOR PITUITARY

67. DIABETES INSIPIDUS
EXCRETION OF ABNORMALLY LARGE
AMOUNTS OF DILUTE URINE
24H URINE VOLUME >50ML/KG AND
OSMOLARITY <300MOSM/L
URINARY FREQUENCY,NOCTURIA,
DAY TIME FATIGUE, POLYDIPSIA

68. COMPLETE D. INSIPIDUS
NEOPLASM CA BRONCHUS-SMALL CELL CA,CA PANCREAS,CA
PROSTATE
CNS DISORDERS MENINGITIS,HEAD
INJURY,CVA,HYDROCEPHALUS,GBS
PULMONARY TB , PNEUMONIA
DRUGS CHLORPROPAMIDE ANTIDEPRESSANTS
HALOPERIDOL CARBAMAZEPINE
CHEMOTHERAPY THIAZIDES MORPHINE NSAIDS
POST-OP PAIN NAUSEA

69. CAUSES
CRANIAL / NEUROGENIC
IDIOPATHIC
TRAUMA / POST SURGICAL
TUMOUR
VASCULAR [SHEEHAN’S SYNDROME,AORTO-CORONARY BYPASS]
GRANULOMA
INFECTIONS
FAMILIAL
NEPHROGENIC
GENETIC
METABOLIC : HYPOKALEMIA , HYPERCALCEMIA
DRUG : LITHIUM , DEMECLOCYCLIN
POISONING :HEAVY METAL
POST OBSTRUCTIVE : PROSTRATE , URETERAL
VASCULAR : SICKLE CELL DISEASE

70. INVESTIGATIONS
• WATER DEPRIVATION TEST
WATER PITUITARY EXOGENOUS
DEPRIVATION VASOPRESSIN VASOPRESSIN
D.I.INCREASE
NORMAL NO
IN URINE
EFFECT
OSMOLARITY

71. TREATMENT
PITRESSIN • 5u / mL im
TANNATE • Q48H
SYNTHETIC • 50 u / mL in isotonic saline
LYSINE
VASOPRESSIN • DRODID nasal spray
• 1-2µg bd iv or s/c
DESMOPRESSIN • 10-20 µg bd/tid nasal spray
• 100-400 µg bd / tid orally

72. DESMOPRESSIN
1-Deamino 8-D Arginine VasoPressin
[DDAVP]
ONSET 15 MIN AFTER INJ, 60 MIN AFTER
ORAL
ACTS SELECTIVELY AT V2 RECEPTORS TO
INCREASE URINE CONCENTRATION
OTHERS:THIAZIDES/CHLORPROPAMIDE
CARBAMAZEPINE
CLOFIBRATE

73. PERIOPERATIVE MANAGEMENT
POST HYPOPHYSECTOMY
• RECOVER IN FEW DAYS TO 6
MONTHS
POST HEAD TRAUMA /
POSTSURGERY
• RECOVER AFTER A SHORTER PERIOD

74. COMPLETE D. INSIPIDUS
JUST BEFORE SURGERYUSUAL DOSE
INTRA NASALLY OR aq.VASOPRESSIN
100 mU IV BOLUS F/B CONSTANT
INFUSION OF 100-200 mU/HR
ISOTONIC IVFs
P.OSMOLARITY HOURLY
IF >290 mOsm/L  HYPOTONIC IVFs
INCREASE VASOPRESSIN INFUSION >200
mU/ HR

75. PARTIAL D. INSIPIDUS
POST OPERATIVELY, INTRANASAL
VASOPRESSIN / PITRESSIN TANNATE
5-10 U /DAY IM

76. CONCERNS: VASOPRESSIN
OXYTOCIC PROPERTIES [CAUTION
PREGNANCY]
CORONARY VASOCONSTRICTOR
[CAUTION CAD]
STICK TO CORRECT DOSE

77. SIADH
WATER OVERLOAD, LOW SERUM
OSMOLARITY,HYPONATREMIA…STILL..
PERSISTENT ADH SECRETION
MORE WATER RETENTION

78. CLINICAL FEATURES
WEIGHT GAIN
LETHARGY
CONFUSION
ABNORMAL REFLEXES
CONVULSION
COMA
….FEATURES OF HYPONATREMIA AND
BRAIN EDEMA

79. DIAGNOSIS
Patient with hyponatremia excrete urine which
is hypertonic relative to plasma….

80. DIAGNOSIS
URINE Na >20 mEq/l
LOW BUN , S.CREATININE, S.URIC ACID , S.
ALBUMIN
S.Na <130 mEq /L
PLASMA OSMOLALITY <270 mOsm /L
HYPERTONIC URINE RELATIVE TO PLASMA
UNABLE TO EXCRETE URINE EVEN AFTER WATER
LOADING
ADH ASSAY IN BLOOD
N.B. : PATIENTS SUSPECTED FOR SIADH SHOULD
BE SCREENED FOR ADRENAL INSUFFICIENCY &
HYPOTHYROIDISM

81. TREATMENT
MILD-MODERATE SYMPTOMS
RESTRICT FLUIDS 500-1000 ML/ DAY
SEVERE
5% SALINE IV 200-300ML OVER SEVERAL
HRS FOLLOWED BY FLUID RESTRICTION
Rx UNDERLYING PROBLEM

82. TREATMENT
DRUGS
PHENYTOIN ,NALOXONE ,BUTORPHANOL
EFFECT ON RELEASE -CLINICALLY
INEFFECTIVE
LITHIUM BLOCK EFFECT OF ADH ON
RENAL TUBULES ,TOXICITY > BENEFITS
DEMETHYL CHLORTETRACYCLINE 900-
1200 mg/day interfere with ability of renal
tubules to concentrate urine

83. PERIOPERATIVE
MANAGEMENT
CONCERNS
ANEMIA
MALNUTRITION
FLUID &ELECTROLYTE IMBALANCE
LOW URINE OUTPUT
DELAYED AWAKENING
MENTAL CONFUSION

84. .

85. ALSO NOTE…..
USUALLY ONLY FLUID RESTRICTION
IS NEEDED ; RARELY, HYPERTONIC
SALINE
AGE OF PATIENT AND TYPE OF
ANESTHETIC AGENT HAVE NO
BEARING WITH INCIDENCE OF SIADH

86. REFERENCES
 ANESTHESIA AND UNCOMMON DISEASES, FLEISHER,5/e
 PITUITARY DISEASE AND ANESTHESIA,M.SMITH & N.P
HIRSH,BJA, 85 (1) 2000
 STOELTING’S ANESTHESIA & COEXISTING DISEASE, 5/e
 HARRISONS PRINCIPLES OF INTERNAL MEDICINE,17/e
 LEE MCGREGOR’S SYNOPSIS OF SURGICAL
ANATOMY,12/e
 REVIEW OF MEDICAL PHYSIOLOGY,WILLIAM F
GANONG,22/e

87. .
READING UNCOMMON THINGS
WHICH WE HAVENT FACED YET
MAY WASTE TIME….
FACING UNCOMMON THINGS
WHICH WE HAVENT READ YET
MAY WASTE LIVES….