Perioperative management of a child with severe hypertension from a catecholamine secreting neuroblastoma

Abstract

Increased catecholamine secretion from neuroblastomas can occasionally be demonstrated, but severe hypertension is uncommon. We report the perioperative management of a 5 year old child with stage III adrenal neuroblastoma who presented with malignant hypertension and high norepinephrine and dopamine levels. Hypertensive crises occurred during anesthesia for surgical biopsy and during chemotherapy. After blood pressure control using phenoxybenzamine and enalapril, doxazosin was used successfully as the preoperative alpha-adrenergic receptor antagonist for surgical tumor resection.

Perioperative management of hypertensive neuroblastoma: A study from the Italian Group of Pediatric Surgical Oncologists (GICOP)

“…Few studies have focused on the perioperative management of HT, and most of these have been case reports [1][2][3][4][5][6][7][8][9]. Both cardiac and neurological complications of HT have been described [10].…”

“…Although the secretion of catecholamines may be increased in NB patients, HT and other symptoms of catecholamine excess frequently observed in pheochromocytoma have been reported in relatively few children with NB (1)(2)(3)(4)(5)(6)(7)(8)(9). This difference is probably owing to the presence of many storage granules in pheochromocytoma, which release large quantities of catecholamines, thereby causing HT.…”

“…A small number of NB do display abundant storage granules and patients can exhibit blood pressure patterns like those of patients with pheochromocytoma [11][12][13][14]. Chemotherapy may result in additional catecholamine release and HT owing to tumor lysis, thus warranting close observation during preoperative cycles [4].…”

“…Whatever the cause of HT in NB, symptoms are generally well controlled by the preoperative administration of alpha-1 adrenergic blocking agents, such as phenoxybenzamine, phentolamine, prazosin and, more recently, doxazosin [3,4,6,9,[17][18][19][20][21][22][23][24][25][26].…”

“…Therefore, the availability of a wide range of rapidly acting medications to treat intraoperative hypertensive peaks is mandatory; these include prostaglandin E1, diuretics, calcium channel antagonists, sodium nitroprusside, hydralazine, magnesium sulfate, phentolamine, adenosine, and fenoldopam [4,6,[20][21][22]. Beta blockers, such as propranolol, labetalol, atenolol and esmolol, may be administered intraoperatively in association with alpha-1 blockers to control catecholamineinduced arrhythmia and tachycardia [4,6].…”