›Diabetes insipidus management
›If urine output > 300 ml/hour and dilute urine
›Desmopressin 1–2 mcg IV or SQ every 12–24 hours
›Monitor serum sodium closely — risk of overcorrection
›Adequate hypotonic fluid replacement
›Replace free water losses
Analgesic and antiemetic support
›Headache management
›Paracetamol 1 g IV or PO every 6 hours
›First-line analgesia
›Avoid NSAIDs if surgical planning or coagulopathy
›Opioid analgesia for severe headache
›Morphine 2–4 mg IV every 4 hours PRN
›Titrate to pain relief with mental status monitoring
›Nausea and vomiting
›Ondansetron 4–8 mg IV every 6–8 hours PRN
›QT prolongation review in cardiac risk patients
›Metoclopramide 10 mg IV every 8 hours as alternative
›Avoid in patients with impaired consciousness
Thyroid hormone replacement
›Central hypothyroidism replacement
›Levothyroxine replacement
›Do NOT start before glucocorticoid replacement
›Starting levothyroxine without steroids can precipitate adrenal crisis
›Initiate once glucocorticoid course established
›Levothyroxine 50–100 mcg PO daily as starting dose
›Titrate based on free T4 levels over weeks
›Monitoring
›Free T4 target mid-normal range
›TSH unreliable in central hypothyroidism
›Transsphenoidal decompression
›Surgical timing
›Urgent within 24–72 hours for declining vision
›Elective within 1 week for stable visual deficits
›Approach
›Endoscopic endonasal transsphenoidal most common
›Sublabial microscopic approach alternative
›Goals
›Decompression of optic chiasm and cranial nerves
›Tumor evacuation and hemorrhage removal
›Visual outcome
›Visual improvement in 70–90% with timely surgery
›Complete recovery more likely with surgery within 72 hours
›Anticoagulation reversal if indicated
›Warfarin — Vitamin K 10 mg IV plus 4-factor PCC
›Target INR < 1.5 before surgery
›Heparin — protamine sulfate 1 mg per 100 units heparin IV
›DOAC — specific reversal agents per agent and availability
›Idarucizumab for dabigatran
›Andexanet alfa for factor Xa inhibitors
Long-term hormone replacement
›Anticipated replacement needs
›Corticosteroids required in 60–80%
›Hydrocortisone 15–25 mg PO daily in divided doses
›Stress dosing education essential
›Thyroid hormone required in 50–60%
›Levothyroxine titrated to free T4
›Testosterone in men — 60–80% require replacement
›Testosterone enanthate 250 mg IM every 2–3 weeks
›Or transdermal gel equivalent
›Desmopressin for diabetes insipidus — 10–25% of patients
›Desmopressin 0.1–0.4 mg PO daily in divided doses
›Or nasal spray 10–40 mcg daily