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 Table of Contents    
CASE REPORT
Year : 2007  |  Volume : 51  |  Issue : 3  |  Page : 237-239  

Anaesthetic management of bilateral phaeochromocytoma in a young female patient


1 DA., MD., Additional Professor, Department of Anaesthesiology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, India
2 MD., Assistant Professor, Department of Anaesthesiology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, India
3 DA., MD., RMO-cum Clinical Tutor, Department of Anaesthesiology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, India
4 PG Student, Department of Anaesthesiology, Institute of Postgraduate Medical Education and Research, SSKM Hospital, Kolkata, India

Date of Acceptance11-Apr-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Sampa Datta Gupta
42, Lake Place, Kolkata - 29
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Source of Support: None, Conflict of Interest: None


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Phaeochromocytoma is a catecholamine secreting tumour that typically occurs in patients of 30 - 50 years age.
A female patient 28-year-old with bilateral phaeochromocytoma presented with hypertension and hyperg­lycemia. Diagnosis was confirmed by CT scan of the abdomen and raised 24 hrs urinary catecholamine and vanillylmandelic acid.
The patient was scheduled for excision of tumour. Pre-operative blood pressure was controlled with prazosin and metoprolol, hyperglycemia was controlled with soluble human insulin. The anaesthetic technique used was general anaesthesia with control of blood pressure during operation and manipulation of tumour with sodium nitroprusside (SNP) infusion and after removal of tumour with noradrenaline infusion and fluid replacement.

Keywords: Phaeochromocytoma; Hypertension; Anaesthetic management.


How to cite this article:
Basu M, Gupta SD, Mukhopadhyay S, Saha S. Anaesthetic management of bilateral phaeochromocytoma in a young female patient. Indian J Anaesth 2007;51:237-9

How to cite this URL:
Basu M, Gupta SD, Mukhopadhyay S, Saha S. Anaesthetic management of bilateral phaeochromocytoma in a young female patient. Indian J Anaesth [serial online] 2007 [cited 2019 May 19];51:237-9. Available from: http://www.ijaweb.org/text.asp?2007/51/3/237/61151


   Introduction Top


Phaeochromocytoma is a catecholamine secreting tumour that originates in the adrenal medulla or in chromaffin tissues along the paravertebral sympathetic chain extending from the pelvis to the base of the skull [1] . More than 95% of all phaeochromocytomas are found in the abdominal cavity and 90 % originate in the adrenal medulla. 10% of these tumours involve both the adrenal glands. Less than 10% of phaeochromocytomas are malignant. Phaeochromocytoma typically occurs in patients of 30 - 50 years age. Approximately 0.1% of the hypertensives suffer from this surgically correctable cause of hypertension which is often fatal if left untreated. Phaeochromocytoma can also occur as part of multiple endocrine neoplasias (MEN). [2]

This case report describes the peri-operative anaesthetic management in a patient with bilateral phaeochromocytoma.


   Case report Top


A 28-year-old, 49 kg, female patient was admit­ted with sudden hypertensive crisis along with vomiting and hyperglycaemia. Blood pressure was 230 / 120 mm of Hg. Blood sugar was 350 mg.dl-1. There was no definite history of headache, palpitation, diaphoresis, pain abdomen. Bilateral phaeochromocytoma was diagnosed by raised level of catecholamines and vanillylmandelic acid (VMA) in 24 hours urine collection, ultrasound and CT -scan. CT­ scan report showed a large mixed dense heterogenous mass with few wall calcification at left adrenal region measur­ing 10.11 cm x 8.02 cm x 7.7cm. Another solid fairly ho­mogenous mass was noted inferomedial to the above mass with an area of continuity measuring 3.85cm x 3.30 cm. On right side a heterogenous mass was noted to originate from lateral limb of right adrenal gland measuring 2.24 cm x 2.01 cm. Other investigations like blood urea, creatinine, haemoglobin percentage, differential count, serum electro­lytes were within normal limits. Her blood pressure was controlled with oral prazosin 10 mg once daily and metoprolol 12.5 mg once daily. ECG was free of ST changes for last 2 weeks, no ventricular ectopics noted. Her blood sugar was controlled with insulin 8 - 8 - 6 unit (soluble human insulin) subcutaneously. Patient was posted for bilateral adrenalectomy when blood pressure was about 140 / 90 mm Hg with no sign of postural hypotension and blood sugar was controlled to 130 mg.dl -1 postprandial. Haematocrit was also near normal.


   Anaesthetic management Top


Alprazolam 0.25 mg P.O. was given at night before operation. Morning doses of oral antihypertensive and di­azepam 10 mg P.O. were given, morning dose of insulin was omitted. Pre-operative blood glucose was 131mg.dl-1, blood pressure was 150/76 mm Hg, heart rate was 76/min, SpO2 was 99% in room air. After securing intravenous access with 16 G intravenous cannula, 5% dextrose infu­sion was started. Monitors were attached for continuous monitoring of NIBP, SpO 2 and ECG. Midazolam 2 mg, fentanyl 100 mcg and ranitidine 50mg were adminis­tered intravenously as premedication. After proper pre­oxygenation patient was induced with propofol 1% 100mg and trachea was intubated with 7.0mm I.D. cuffed endot­racheal tube after achieving adequate relaxation with rocuronium bromide 50mg. Lidocaine (without preserva­tive) 1.5 mg.kg-1 body weight intravenously was adminis­tered 1 minute before laryngoscopy to minimize adverse cardiovascular effects of laryngoscopy and intubation. Blood pressure after induction was 126/70 mm Hg and after intubation was 144/70 mm Hg. A central venous access was established through subclavian approach after intubation for continuous central venous pressure monitor­ing. Maintenance of anaesthesia was done by positive pres­sure ventilation with O2 and N2O as 50% : 50% along with supplemental doses of fentanyl and vecuronium bromide. Propofol was administered by a syringe pump at a rate of 100 mg.hr-1.

During the excision and manipulation of tumour mass of both sides there was rapid fluctuation of blood pressure which rose maximum upto 280/160 mm of Hg and was controlled by infusion of sodium nitroprusside (50 mg SNP in 500 ml of 5% dextrose) incrementally throughout the procedure as per requirement. During removal of second tumour the precipitous fall of blood pressure was restored by rapid infusion of crystalloid (Ringer's lactate 4 L) and colloids (Hydroxyethyl starch 6% 1 L). Hydrocortisone 400mg was administered immediately after removal of 2 nd tumour mass. Blood pressure was restored by infusion of noradrenaline. Urine output was adequate throughout the procedure ( at a rate of 1.5 ml.kg-1.hr-1). Capillary blood sugar level was monitored and adjusted with infusion of insulin as per sliding scale throughout the procedure. At the end of surgery incision line was infiltrated with 0.25% bupivacaine (20 ml). Residual neuromuscular blockade was reversed with neostigmine 0.05 mg.kg -1 with glycopyrrolate 0.01 mg.kg -1 at the end of surgery. Patient was kept in ICU under close supervision for continuous monitoring of NIBP, CVP, SpO2 % and capillary blood glucose (CBG) changes and urine output for next 24 hrs for proper man­agement and quick postoperative recovery. To maintain B.P., noradrenaline infusion was continued in the post-op­erative period. Hydrocortisone 100 mg I.V. 6 hourly was also administered. When patient's haemodynamic status became stable, noradrenaline infusion was discontinued.

On subsequent post operative days, patient's B.P. and blood glucose level gradually came to near normal, patient was discharged on 16th post-operative day with oral hydro­cortisone tablet 10 mg in the morning and 5 mg in the evening.


   Discussion Top


A substantial proportion of phaeochromocytoma se­cretes predominantly norepinephrine, sometimes paroxys­mal but usually sustained and often in huge quantities. Sus­tained severe hypertension is often the commonest pre­sentation of phaeochromocytoma. [3] There is also vasoconstriction in arteriolar and venous sites due to released nore­pinephrine and thereby decreasing the circulating blood volume. Diagnosis is usually confirmed by raised urinary catecholamine and VMA in 24hrs urine. Localization of tumour is accurately done by CT scan, MRI, MIBG scan. [4],[5]

Main aim is resolution of symptoms in the pre- op­erative period so that wide variation in arterial pressure does not take place during operation. This is achieved by antiadrenergic drugs i.e. alpha (á) and beta (â) blockers. The sympathetic blockade is achieved first by á adren­ergic blocker followed by á â- blocker. Alpha blockade results in vasodilatation and tachycardia which is controlled by beta blockers. If beta blockade is achieved first then there may be unopposed vasoconstriction in skeletal muscles causing hypertension. Twenty four hours ambula­tory blood pressure monitoring should show a blood pres­sure of 140/90 mm of Hg and a heart rate of less than 100 bpm. Lying and standing blood pressure should show a postural drop upto but not less than 80/45 in standing posi­tion. More drop indicates inadequate hydration. ECG should be free of ST changes for at least 2 weeks. Mortality is due to ignoring subtle changes of cardiomyopathy.

In our case we used prazosin, a selective á1- ­blocker[4],[5]. Prazosin interferes selectively with post synap­tic á- adrenergic receptor function. Prazosin causes less tachycardia and postural hypotension than other á­ adrenoreceptor blockers. Here we used metoprolol as -â blocker in small doses. [6]

Goal of anaesthetic management should be aimed to provide optimal surgical condition and to suppress the re­sponses to endotracheal intubation, surgical stimulation, tumour handling and devascularization. Here we preferred general anaesthesia for our patient as it was a transab­dominal approach.

Pre-medication should be according to choice of anaesthesiologists but drug causing histamine release should be avoided. [6] Here in our case we used benzodiazepine as premedication to reduce anxiety induced activation of sym­pathetic nervous system.

In our case we used propofol 1% as induction agent and fentanyl, a potent short acting opioid as analgesic as both of them can modify the haemodynamic effect of laryn­goscopy and intubation. Lidocaine (preservative free) 1.5 mg.kg-1 i.v. was administered 1 min. before laryngoscopy to attenuate pressure response of laryngoscopy and intubation. [7]

Rocuronium was used for intubation instead of suxamethonium because latter causes histamine release and compression of abdominal tumour during fascicula­tion [8] . Vecuronium was used as muscle relaxant for main­tenance of anaesthesia due to its cardiovascular stability and inability to release histamine. Sodium nitroprusside in­ fusion was used to control rise of blood pressure during handling of tumour [1]. After removal of tumour blood pres­sure was maintained with noradrenaline infusion and crys­talloids and colloids. Hydrocortisone replacement was also given. Glucocorticoid and mineralocorticoid cover is man­datory for patients undergoing bilateral adrenalectomy [5].

To conclude, proper diagnosis and management of phaeochromocytoma is necessary. Early involvement of anaesthesiologists is also essential. Today early diagnosis is possible with CT-scan, MRI and by 24 hrs urinary cat­echolamine and its metabolites estimation. With better un­derstanding of pathophysiology of phaeochromocytoma, management of hypertension with á- adrenoreceptor blocker and if necessary using â- blocker is possible. Proper monitoring, adequate fluid replacement and also availabil­ity of drugs which can rapidly alter blood pressure and development of newer sophisticated techniques of anaes­thesia make the surgical resection of phaeochromocytoma as safe as other tumour resection. Operative mortality has also reduced now-a-days.

 
   References Top

1.Hull CJ. Phaeochromocytoma. Diagnosis, preoperative prepa­ration and anaesthetic management. Br J Anaesth 1986; 58: 1453 - 58.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Thomas JL, Bernardinodino ME. Phaeochromocytoma in mul­tiple endocrine adenomatosis. JAMA 1981; 245: 1467 - 9.  Back to cited text no. 2
    
3.Magner WM, Giffor Jun. Phaeochromocytoma overview In: Swabs JD ed, Text book of hypertension Oxford Blackwell Sci­entific 1994: 941 - 58.  Back to cited text no. 3
    
4.Roberts C. Prys. Phaeochromocytoma - recent progress in its management. Br J Anaesth 2000; 85: 44 - 57.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Pullertis J, Ein Sigmud, Williamson S. Anaesthesia for Phaeochromocytoma. Can J Anaesth 1988; 35: 526 - 534.  Back to cited text no. 5
    
6.Wallece JM, Gill DP. Prazosin in diagnosis and management of Phaeochromocytoma. JAMA 1978; 240: 2752 - 3.   Back to cited text no. 6
    
7.Stoelting RK, Dierdorf SF. Endocrine diseases. Anesthesia and Co-Existing disease. 4 th edition 2002; 430 - 434.  Back to cited text no. 7
    
8.Stoelting RK, Blood pressure and heart rate changes during short duration laryngoscopy for tracheal intubation: influence of vis­cous or intravenous lidocaine. Anesth Analg 1978; 57: 197 - 9.  Back to cited text no. 8
    




 

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