Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

Abstract

Objective To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). Methods This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. Results Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. Conclusions An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction. Keywords Pheochromocytoma • Paragangliomas • Presurgical management • Anesthetic treatment • α-blockadeThis article was elaborated by the multidisciplinary adrenal/ paraganglioma team of the Hospital Ramón y Cajal. Madrid (Spain).

Management of Patients with Treatment of Pheochromocytoma: A Critical Appraisal

“…Communication between surgeons and anesthesiologists is crucial for good execution of surgeries. There are three critical intraoperative moments during an adrenalectomy for pheochromocytoma: orotracheal intubation, tumor dissection and phases after ligation of the main adrenal vein [ 53 ]. Hemodynamic intraoperative monitoring should include, in addition to basic monitoring such as an electrocardiogram, noninvasive BP, pulse oximeter and capnography in an artery so that there are real-time accurate measures of BP [ 53 ].…”

“…The most important aspect to achieve is a deep anesthetic level so the cardiovascular system can be inhibited in response to the release of catecholamines [ 3 ]. There are several recommendations that should be followed: locoregional anesthesia should be avoided because it can cause the blocked regions to be more responsive to catecholamines, histamines should be avoided as they can release catecholamines from chromaffin granules, fentanyl should be preferred to morphine, propofol should be used instead of ketamine and anxiolytic drugs should be administered to patients before surgery to minimize stress stimuli [ 53 ].…”

“…From the point of view of the anesthesiologist, several different complications can occur during an adrenalectomy. Hypertension crises are usually related to manipulation of the tumor [ 53 ]. SPB > 200 mmHg for more than 1 min requires treatment [ 53 ].…”

“…Hypertension crises are usually related to manipulation of the tumor [ 53 ]. SPB > 200 mmHg for more than 1 min requires treatment [ 53 ]. It is probably not necessary to have a reaction from the anesthesia team below this limit.…”

“…It is probably not necessary to have a reaction from the anesthesia team below this limit. Several intraoperative drugs can be used, such as nitroglycerin (nitric oxide modulators), nicardipine (calcium channel blockers), phentolamine (alpha-adrenergic antagonist) or even magnesium sulphate to lower blood pressure [ 53 ]. Arrythmias may also happen due to the release of epinephrine or norepinephrine during manipulation of the tumor.…”