Hemodynamic response, coughing and the incidence of cerebrospinal fluid leakage on awakening with an endotracheal tube or laryngeal mask airway in place after transsphenoidal pituitary surgery: a randomized clinical trial

We aimed to compare systemic and cerebral hemodynamics and coughing during emergence after pituitary surgery after endotracheal tube (ETT) extubation or after replacing ETT with a laryngeal mask airway (LMA). Patients were randomized to awaken with an ETT in place or after replacing it with an LMA. We recorded mean arterial pressure (MAP), heart rate, middle cerebral artery (MCA) flow velocity, regional cerebral oxygen saturation (SrO2), cardiac index, plasma norepinephrine, need for vasoactive drugs, coughing during emergence, and postoperative cerebrospinal fluid (CSF) leakage. The primary endpoint was postoperative MAP; secondary endpoints were SrO2 and coughing incidence. Forty-five patients were included. MAP was lower during emergence than at baseline in both groups. There were no significant between-group differences in blood pressure, nor in the number of patients that required antihypertensive drugs during emergence (ETT: 8 patients (34.8%) vs. LMA: 3 patients (14.3%); p = 0.116). MCA flow velocity was higher in the ETT group (e.g., mean (95% CI) at 15 min, 103.2 (96.3-110.1) vs. 89.6 (82.6-96.5) cm·s-1; p = 0.003). SrO2, cardiac index, and norepinephrine levels were similar. Coughing was more frequent in the ETT group (81% vs. 15%; p < 0.001). CSF leakage occurred in three patients (13%) in the ETT group. Placing an LMA before removing an ETT during emergence after pituitary surgery favors a safer cerebral hemodynamic profile and reduces coughing. This strategy may lower the risk for CSF leakage.