Introduction: Hypopituitarism has traditionally been viewed as a rare sequela of traumatic brain injury (TBI), but its significance is increasingly recognized in critically ill patients. The associated hormonal derangements can complicate routine ICU care. We describe a patient with hypopituitarism secondary to facial gunshot trauma and discuss the complexities of managing endocrine dysfunction postoperatively.
Description: A 16-year-old male with post-traumatic hypopituitarism following a facial gunshot wound was admitted to the surgical ICU after maxillary reconstruction with a free fibula flap. He required hormone repletion for central hypothyroidism, adrenal insufficiency, and central diabetes insipidus. His desmopressin and levothyroxine were continued; prednisone was escalated to stress-dose hydrocortisone. Despite initially stable flap signals and hemodynamics, he developed progressive hypernatremia (peak 159 mmol/L) on postoperative day 4. Escalating DDAVP doses and titration of hypotonic fluids were required to prevent further sodium rise while avoiding rapid correction. Hourly monitoring and interdisciplinary coordination were essential to stabilize electrolytes without compromising cerebral safety or flap viability. He was discharged on hospital day 15 after gradual endocrine stabilization.
Discussion: Hypopituitarism after traumatic brain injury can present significant challenges in the ICU. This patient required coordinated management of adrenal insufficiency, central hypothyroidism, and central diabetes insipidus. The development of hypernatremia in the setting of NPO status and fluctuating urine output created a narrow therapeutic window. Desmopressin dosing and fluid administration were carefully adjusted to avoid both sodium overcorrection and further dehydration. The interplay between endocrine instability, surgical recovery, and fluid balance made this a complex case requiring close monitoring and frequent clinical decisions. This experience underscores the importance of anticipating hormonal complications in patients with prior TBI, particularly during periods of physiological stress such as major surgery. Early involvement of endocrinology and structured monitoring protocols are essential in preventing avoidable complications in this high-risk population during critical illness.
