Perioperative care of phaeochromocytoma

Connor, David; Boumphrey, S.

doi:10.1093/bjaed/mkv033

Cited by 41 publications

(81 citation statements)

References 13 publications

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“…Whilst guidelines recommend liberal fluid administration pre-and perioperatively to correct hypovolemia and to avoid hypotension after tumor resection [3, 14], some experts have challenged these recommendations [18,33,34]. Since intraoperative hemodynamics are extremely unpredictable, extended monitoring seems mandatory especially in large tumors to provide individualized therapy and to avoid overly liberal and potentially harmful fluid administration [15,16,18,33], as found in at least 8% of PCC patients perioperatively [7].…”

Section: Discussionmentioning

confidence: 99%

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

et al. 2019

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Background Hemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications. Methods Ten patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters. Results Applying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg −1 h −1 , p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min −1 m −2 , p = 0.005; HIAT: 2.08 vs. 2.56 l min −1 m −2 , p = 0.225). Conclusions As vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course. Trial registration: ClinicalTrials.gov, Identifier: NCT01425710.

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Section: Discussionmentioning

confidence: 99%

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

et al. 2019

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“…However, it is difficult to determine pre-operatively whether this response will be appropriate in a given patient. Moreover, in human patients chron-ic secretion of catecholamines by phaeochromocytomas will tend to downregulate adrenergic receptors and removal of the affected gland will abruptly decrease the plasmatic levels of circulating catecholamines (Connor and Boumphrey, 2016). One of the effect of steroids (endogenous or exogenous) is to increase the sensitivity of those receptors to catecholamines (Shaikh et al, 2012).…”

Section: Discussionmentioning

confidence: 99%

Anaesthetic management and complications of canine adrenalectomies: 41 cases (2007–2017)

Merlin¹,

Veres-Nyéki

2019

Acta Veterinaria Hungarica

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Little information is available about the management of adrenalectomies in veterinary anaesthesia. The aim of this study was to describe the anaesthetic techniques, the complication rate and outcome of these cases. Data were collected retrospectively from patients' records. Descriptive statistics were performed with Student's t-tests and Chi-square tests where appropriate. Forty-one cases were included. The mean age was 124.7 ± 29.4 months and the median body weight was 23.1 kg (5.3–69 kg). Carcinoma was the most common diagnosis (34.1%). Premedication was most commonly achieved with methadone alone (70.7%) IV. Propofol was the most common induction agent (39%). An infusion of opioids (80.4%) and an epidural injection of morphine (70.7%) were the most common analgesic techniques. Hypotension was the most common complication observed (51.2%). The mortality rate was 14.6%. The lowest recorded oesophageal temperature was statistically associated with the incidence of haemorrhage (P = 0.025). The invasion of the vena cava (P = 0.001) was significantly associated with haemorrhagic complications. The survival rate was better when patients received hydrocortisone intra-operatively (P = 0.026). This study highlights some possible association between the anaesthetic management and the outcome of the procedure.

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“…[5][6][7] If a hypertensive crisis was to arise during surgery, this can be managed with infusion or boluses of phentolamine. 8 Phentolamine is a short-acting reversible non-selective alphaadrenergic antagonist and is the optimal treatment for hypertensive emergencies. 8 However, it is currently not available in the UK and was not available for the surgery performed in our case.…”

Section: Discussionmentioning

confidence: 99%

“…8 Phentolamine is a short-acting reversible non-selective alphaadrenergic antagonist and is the optimal treatment for hypertensive emergencies. 8 However, it is currently not available in the UK and was not available for the surgery performed in our case. Alliance Pharmaceuticals / Novartis discontinued its UK production in August 2012 and, according to the Specialist Pharmacy Service, there are currently no alternative injectable alpha blockers available within the UK; importers are experiencing difficulties sourcing formulations of either phentolamine or the alternative agent phenoxybenzamine.…”

Section: Discussionmentioning

confidence: 99%

Lesson of the month 2: Blunt abdominal trauma: atypical presentation of phaeochromocytoma

et al. 2018

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A 26-year-old man presented following blunt abdominal trauma to a regional major trauma centre for emergency embolisation of a retroperitoneal bleed from a presumed renal laceration. Imaging had also revealed a large right suprarenal mass. Embolisation resulted in a hypertensive crisis raising the suspicion of a metabolically active adrenal tumour. The course was further complicated by the development of ischaemic bowel requiring emergency laparotomy. Intraoperatively he became haemodynamically unstable from an actively haemorrhaging lesion. Emergency laparotomy and adrenalectomy was performed as a life-saving procedure. Histology confirmed a phaeochromocytoma. The patient made a gradual recovery and was discharged home with no sequelae. Definitive management of phaeochromocytoma is surgical resection which requires prolonged preoperative optimisation with alpha receptor blockers to adequately control blood pressure and prevent hypertensive crises. Parenteral alpha receptor blockers, such as phentolamine, are optimal treatment for intraoperative hypertensive emergencies, yet they are currently not available in the UK.

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Perioperative care of phaeochromocytoma

Abstract: Initial diagnosis is achieved via analysis of metanephrine levels followed by CT or MRI.• Half of phaeochromocytomas are diagnosed incidentally on abdominal imaging.

Cited by 41 publications

References 13 publications

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

Anaesthetic management and complications of canine adrenalectomies: 41 cases (2007–2017)

Lesson of the month 2: Blunt abdominal trauma: atypical presentation of phaeochromocytoma

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