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Anesthetic Management of a Patient of Pituitary Microadenoma with Low Ejection Fraction for Inferior Petrosal Sinus Sampling

Background: Adrenocorticotropic hormone secreting pituitary adenoma is though quite rare yet associated with increased morbidity and mortality due to severe comorbidities associated with them. Inferior petrosal sinus sampling (IPSS) is the gold standard invasive procedure for the anatomical localization for Cushing’s disease. Case Description: We report two typical cases of Cushing’s disease with low–ejection fraction who underwent IPSS and discuss the difficulties encountered and their management. Both of them were female patients of age 40 and 38 years, respectively. They presented with similar complaints of weight gain, facial hair, and body ache and after clinical examination and investigations, they were diagnosed to have Cushing’s disease with pituitary microadenoma. Hypertension and diabetes mellitus were present with echo findings of ejection fraction of 30 and 35%, respectively. IPSS was performed under general anesthesia. Patients were hemodynamically stable throughout the procedure and we avoided any tachycardia, hypoxia, hypercarbia, hypothermia, and proper analgesia was ensured. Blood sugar levels were kept within normal limits. Conclusion: Anesthetic implications due to Cushing’s disease include hyperglycemia, hypertension, proximal muscle weakness, and skin thinning. Delicate skin and osteoporosis cause difficulty in venous access and increases risk of spontaneous fractures. A thorough understanding of preoperative assessment of airway, neurological, and endocrine status were helpful for our management.