Pheochromocytoma is a catecholamine-secreting tumor that requires special anesthetic considerations. Preoperatively, patients undergo alpha-adrenergic blockade to control hypertension and optimize volume status. Intraoperatively, anesthesiologists must carefully control blood pressure fluctuations during tumor handling to prevent hypertensive crises or hypotension after resection. Postoperatively, patients are monitored for rebound hypotension or hypoglycemia from decreased catecholamine levels.
Blood pressure optimization is important in pheochromocytoma patients before going to surgery. It is important for the anesthesia providers to diagnose, optimize and manage those patients..
Blood pressure optimization is important in pheochromocytoma patients before going to surgery. It is important for the anesthesia providers to diagnose, optimize and manage those patients..
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3. ANATOMY
Paired structures positioned superior and medial to kidneys in retroperitoneal
space
Supplied by 3 arteries and 1 vein
Accessory areas for occurrence of pheochromocytoma- Mediastinum, Bladder,
Neck, Sacrococcygeal region, or anal or vaginal areas.
Organs of Zuckerkandl - paraganglia around the aorta
Cortex • Mesodermal tissue near gonads
Medulla • Chromafin ectodermal cells of neural crest
4. PHYSIOLOGY
Adrenal medulla secretes:
Found in all the chromaffin cells of sympathetic nervous system
EPINEPHRINE NOREPINEPHRINE DOPAMINE
12. PREOPERATIVE OPTIMIZATION
Major goals : Control hypertension and to facilitate intravascular volume
expansion
Administration of α-adrenergic blockers –
• Phenoxybenzamine, prazosin, terazosin, doxazosin
13. PHENOXYBENZAMINE
Non-selective, non-competitive, long acting α blocker
Postoperative refractory hypotension
Stopped 24-48 hours before surgery
Dose is 10 mg two or three times a day in adults
Reflex tachycardia (β1 stimulation)
Somnolence., Nasal congestion
14. PRAZOSIN, TERAZOSIN AND DOXAZOSIN
Specific α1 adrenergic receptor blockers
Shorter duration of action
Lesser side effects
Prazosin (2-5mg, twice or thrice a day)
Terazosin (2-5 mg daily)
Doxazosin (2-8 mg daily)
15. α-METHYL-PARA-TYROSINE (α-METYROSINE)
• Decreases the biosynthesis of catecholamines by competitive inhibition.
• Administered a minimum of 2 to 3 days before surgery.
CALCIUM CHANNEL BLOCKERS
Inhibit nor-epinephrine induced calcium influx
Oral Nicardipine 30 mg twice a day is recommended.
MAGNESIUM SULPHATE
CAUTION!!! Adequate α blockage may result in tachycardia. This tachycardia is
managed with selective β1 antagonists . β blockers are started only after complete α
blockade.
16. Assessment of adequate optimization
ROIZEN CRITERIA for adequate α adrenergic blockade.
17. Premedication
Phenoxybenzamine should be stopped 48-72 hours preoperatively
Selective α blocker – prazosin and doxazosin may be continued till surgery.
β blockers to be continued if they have been started
Adequate anxiolysis
Patients encouraged to consume fluid and salt to facilitate volume expansion.
Adequate sedation and analgesia – invasive procedues
Airway – attenuate intubation response
18. SURGICAL APPROACH
Commonly done by the laparoscopic approach
2 approaches - Retroperitoneal and Transabdominal
Slow insufflation of CO2 , gradual tilting of patient and low intra-abdominal
pressure is recommended
Risk factors for intraoperative haemodynamic
instabilityarehighpreinductionplasmanorepinephrine levels, large tumor size,
profound postural drop after commencement of α blockade and a preinduction
MAP above 100 mmHg.
19. INTRAOPERATIVE MANAGEMENT
Anaesthetic Technique –
• General anaesthesia with intubation and controlled
Anaesthetic concerns –
• Hypertensive crisis during tumor handling and hypotension after devascularization is a
concern.
• Should prevent catecholamine release by anaesthetic, surgical manoeuvers and drugs.
Drugs to be avoided - ketamine, suxamethonium, atracurium, pancuronium,
halothane, morphine, pethidine, droperidol and metoclopramide
Catecholamine release is also provoked by tracheal intubation, raised intra-abdominal
pressure and pain.
20. Minimal haemodynamic fluctuations due to tumor handling, as patients are more
prone for severe hypertension and arrhythmias.
All episodes of hypotension should be managed promptly, especially after tumor
devascularization.
OT SETUP –
• Ready infusions of nitroglycerine, nitroprusside, nicardipine
• Esmolol for heart rate control
• Vasoconstrictors such as norepinephrine, dopamine and vasopressin
• Colloids for rapid volume expansion
21. MONITORING
Electrocardiogram with a V5 lead
Core temperature
Pulse oximetry
Intra-arterial BP monitoring
Central venous pressure monitoring
Urinary catheter
Pulmonary artery catheter or transesophageal echocardiography
22. ANAESTHETIC MANAGEMENT
Induction - minimize hemodynamic changes and allow for adequate depth of
anesthesia during tracheal intubation
Lidocaine 4% solution, 1.5 mg/kg IV
Inhalational agents –
• Used for maintenance
• Desflurane - may provoke sympathetic stimulation and subsequent catecholamine
release
• Halothane - potential to incite arrhythmias
23. Drugs to Control Intraoperative
Hypertension
NICARDIPINE - Infusion of 5–15 mg/hr. ↑ by 2.5 mg/hr every 15 min
PHENTOLAMINE - 1-mg IV boluses every 5–10 min. Infusion 0.1–2 mg/min
NITROGLYCERIN - 20–40 μg boluses every 5–10 min to effect. Infusion 5–20
μg/min initial (max dose 400 μg/min)
NITROPRUSSIDE - Infuse initially with 0.5–1.5 μg/kg/min to maximum of 8
μg/kg/min over 1–3 hr
PROPRANOLOL - 1-mg boluses to total 10 mg
ESMOLOL - 5–10-mg boluses, Infuse at 0.25–0.5 μg/kg/min
LABETALOL - 5–10-mg boluses every 20–30 min to maximum dose 150 mg
24. Managing hypotension after tumor
devascularization
BP may decrease very quickly after venous drainage of the tumor is interrupted
vasodilators being administered should be discontinued
BP support - vasopressors, such as norepinephrine and vasopressin, and
administering fluids
Continued vasodilator support may indicate inadequate resection or previously
undiagnosed extra-adrenal tumor
25. POSTOPERATIVE MANAGEMENT
Postoperative hypotension can be due to reduced circulating catecholamine levels
post–tumor resection, hypovolemia, or residual effects of phenoxybenzamine.
Treated with volume administration, norepinephrine, vasopressin
Patient somnolent – narcotic requirement may decrease.
Hypoglycemia - result of decreased catecholamine levels (epinephrine secreting
tumour)
Persistent hypertension after removal of a pheochromocytoma occasionally
signifies - residual pheochromocytoma tumor
26. THANK YOU
REFERENCES:
1. STOELTING'S ANESTHESIA AND CO-
EXISTING DISEASE – 6TH ED
2. YAO & ARTUSIOS ANESTHESIOLGY,
PROBLEM ORIENTED PATIENT
MANAGEMENT – 9TH ED
3. MILLER’S ANAESTHESIA – 8TH ED
Editor's Notes
metaiodobenzylguanidine (MIBG)
β-Blockers can be a useful adjunct to control BP in the intraoperative phase, particularly if tachycardia accompanies use of systemic vasodilators. They should, however, not be used as the first-line agent for treatment of intraoperative hypertension due to the concern about unopposed α-agonism.
