Phaeochromocytoma removal and postoperative hypoglycaemia

Abstract

SummaryA cme of postoperative hypoglycaemia ,following removal of a phaeochromocytoma is presented. The Iiypogl~~cuemia is due to a reactive rise in insulin and is augmented by alpha adrenoceptor blocking agents. Beta adrenoceptor blockers impair recovery ,from this hypoglycaemia. Frequent monitoring of blood glucose and the administration of an appropriate solution of dextrose both during and after this operation is recommended. Key wordsSurgery; phaeochromocytoma. Meraholism; hypoglycaemia.The problems encountered in the removal of a phaeochromocytoma have been well described and concern mainly the peri-operative monitoring and management of heart rate and rhythm. blood pressure and fluid balance. I Hypoglycaemia is a complication of phaeochromocytoma removalg that has received little attention in the anaesthetic literature. and we report such a case hcre. Case historyA 42-year-old, 50-kg female with hypertension and a history of a myocardial infarct complicated by a transient cerebral ischaemic attack and two embolic episodes to the lower limbs 2 years before admission. was found to have raised catecholamine levels (noradrenaline 1 1957 pg/ml. adrenaline 136 pg/ml. normal values being 65-320 and &65 pg/ml respectively). A paraaortic phaeochromocytoma was found on CT scan. She was treated for 3 weeks preoperatively with phenoxybenzamine 40 mg four times a day and sotalol 80 mg three times a day, with good control of her blood pressure and heart rate. Pre-operative blood sugars were mildly but consistently elevated between 6.6 and 7.6 mmol/litre (normal range 3.5-5.5). The phenoxybenzamine and sotalol were continued up to the morning of operation. She was premedicated with droperidol 7.5 mg and fentanyl 100 pg. Anaesthesia was induced with fentanyl 500 pg, droperidol 12.5 mg and thiopentone 100 mg, and muscle relaxation was achieved with pancuronium (6 mg). Anaesthesia was maintained with nitrous oxide, oxygen and 1-2O/0 enflurane, her blood pressure and heart rate being controlled with a sodium nitroprusside infusion and incremental doses of propranolol (total 6 mg). During the operation she was given a total of 1.5 litres of 5% dextrose, 3 litres of Hartmann's solution, I litre of plasma and 2 litres Muscle relaxation was easily reversed with neostigmine 2.5 mg and atropine 1.2 mg and at this time she was noted to be drowsy, but obedient to commands.She was transferred to the intensive therapy unit, where she was found to be slighly hypotensive (blood pressure 90/60 mmHg) and very drowsy. She was given plasma and Hartmann's solution to treat the hypotension, with good effect, but the drowsiness persisted. Blood glucose 30 minutes postoperatively was found to be 1.6 mmol/litre. She was immediately given 10 g dextrose intravenously, and became more alert and responsive; thereafter, infusions of 10% dextrose and 150 ml of Hartmann's solution were given per hour. This maintained her blood glucose between 3.8 and 4.7 mmol/litre. She received a total of 201 g of dextrose and 5.5 litres of intravenous fluid over 24 ...

Hypolgcaemic encephalopathy following surgery on phaeochromocytoma

“…',* Both C-pcptidc and insulin are secreted by bcta-cells of the pancreas and exist in 1 : 1 molar proportion. 8 The constant catecholamine secretion by the tuniour also depletes the glycogen store in the liver." Thus.…”

Pheochromocytoma: Current Approaches and Future Directions

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Perioperative Management of Endocrine Active Adrenal Tumors

“…Another potential mechanism could be an increased glucose uptake in peripheral tissues. [37,38] Following complete or partial bilateral adrenalectomy or unilateral partial adrenalectomy of a single remaining adrenal gland, attention should be paid to the possibility of adrenal insufficiency. [6] Postoperative follow-up According to the European Endocrine Society guidelines, biochemical screening should be undertaken by measuring either plasma metanephrines or urinary levels of metanephrines and 3-methoxytyramine in a properly collected 24-h urine sample ideally 2-6 weeks after surgery to confirm complete PPGL resection.…”