Clinical Approach to Sodium Homeostasis Disorders in Children with Pituitary-Suprasellar Tumors

Children with pituitary-suprasellar tumors are at high risk of developing sodium metabolism disorders since the tumoral mass itself or surgical and medical treatment can damage AVP release circuits. Additional risk factors are represented by the use of hypotonic fluids, the young age, total parenteral nutrition, and obstructive hydrocephalus secondary to tumor pathology. The most frequent hyponatremic disorders related to AVP in these patients are the syndrome of inappropriate ADH secretion and the cerebral/renal salt wasting syndrome, while hypernatremic conditions include central diabetes insipidus (CDI) and adipsic CDI. The main challenge in the management of these patients is to promptly distinguish the AVP release disorder at the base of the sodium imbalance and treat it correctly by avoiding rapid sodium fluctuations. These disorders can coexist or follow each other in a few hours or days; therefore, careful clinical and biochemical monitoring is necessary, especially during surgery, the use of chemotherapeutic agents, or radiotherapy. This monitoring should be performed by experienced healthcare professionals and should be multidisciplinary, including pediatric endocrinologists, neurosurgeons, and oncologists since maintaining sodium homeostasis also plays a prognostic role in terms of disease survival, therapeutic response, hospitalization rate, and mortality. In this review, we analyze the management of sodium homeostasis disorders in children with pituitary-suprasellar tumors and discuss the main challenges in the diagnosis and treatment of these conditions based on literature data and over 30 years of clinical experience at our Department of Pediatric Endocrinology.

General ICU Care of the Neurological Patient

Critically ill patients with acute neurologic conditions are at high risk for development of dysfunction of multiple extracerebral organs. They frequently need airway and ventilator support, and a lung-protective strategy is appropriate. Hemodynamic support is critical to prevent secondary brain injury from hypotension. These patients are at high risk for infectious complications and development of sepsis. Electrolyte abnormalities are common, particularly disorders of sodium metabolism. Controversy continues regarding optimal hemoglobin levels for transfusion. Allowing mild hyperglycemia does not seem to be harmful, though hypoglycemia should be avoided. Steroids may be indicated for specific neurologic diseases but otherwise have little role in the intensive care unit, except for refractory septic shock. Critically ill patients with acute neurologic conditions are very catabolic and require early enteral nutrition support, accompanied by stress ulcer prophylaxis in most circumstances. Optimizing extracerebral organ support can have a significant impact upon outcomes from acute neurologic conditions.