Abstract
Pheochromocytoma and paraganglioma are rare endocrine tumors that pose significant challenge to anesthesiologists. Increased sympathetic activation during induction of anesthesia, tracheal intubation, and surgical incision, and surges of catecholamine release during manipulation of the tumor can precipitate severe hemodynamic instability. Intraoperative complications include malignant hypertension, arrhythmia, myocardial infarction, acute cardiac decompensation, pulmonary edema, and stroke. Careful preoperative preparation with α- and β-blockers and oral intravascular fluid expansion have been shown to decrease the incidence and severity of perioperative hemodynamic instability. Preoperative tests should include 24-h urine catecholamine levels and cardiac evaluation with an electrocardiogram and an echocardiogram. In addition to standard intraoperative monitors, all patients should have an arterial line placed prior to induction of anesthesia. Most patients receive general anesthesia for these surgeries. During the induction of anesthesia, a deep plain of anesthesia and paralysis should be achieved prior to tracheal intubation, to avoid excessive sympathetic stimulation. Potent arterial and venous vasodilators should be readily available to treat hypertensive crises during anesthesia. Arrhythmias should be treated promptly with β-blockers and antiarrhythmic agents. Vasopressors are usually needed to treat hypotension after tumor resection. All vasodilators and vasopressors should be infused via central venous access. Maintenance of general anesthesia is achieved with a volatile anesthetic, with the careful titration of narcotics. The goal of fluid management is to achieve euvolemia. Fluid management should be guided by dynamic parameters of fluid responsiveness. All patients should be recovered in an intensive care unit. Elderly patients are at higher risk for postoperative complications and prolonged hypotension after tumor resection. Care of pheochromocytoma in pregnancy requires a multidisciplinary approach with an endocrinologist, obstetrician, surgeon, and anesthesiologist to best prepare for the timing of surgical resection.
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Ramakrishna H. Pheochromocytoma resection: current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol. 2015;31(3):317–23. PubMed PMID: 26330708. Pubmed Central PMCID: PMC4541176. Epub 2015/09/04. Eng
Lenders JW, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma. Lancet (London, England). 2005;366(9486):665–75. PubMed PMID: 16112304. Epub 2005/08/23. eng
Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: review of perioperative management of blood pressure and update on genetic mutations associated with pheochromocytoma. J Clin Hypertens (Greenwich). 2013;15(6):428–34. PubMed PMID: 23730992. Pubmed Central PMCID: PMC4581847. Epub 2013/06/05. eng
Fishbein L, Merrill S, Fraker DL, Cohen DL, Nathanson KL. Inherited mutations in pheochromocytoma and paraganglioma: why all patients should be offered genetic testing. Ann Surg Oncol. 2013;20(5):1444–50. PubMed PMID: 23512077. Pubmed Central PMCID: PMC4291281. Epub 2013/03/21. eng
Lebuffe G, Dosseh ED, Tek G, Tytgat H, Moreno S, Tavernier B, et al. The effect of calcium channel blockers on outcome following the surgical treatment of phaeochromocytomas and paragangliomas. Anaesthesia. 2005;60(5):439–44. PubMed PMID: 15819762. Epub 2005/04/12. eng
Apgar V, Papper EM. Pheochromocytoma. Anesthetic management during surgical treatment. AMA Arch Surg. 1951;62(5):634–48. PubMed PMID: 14818537. Epub 1951/05/01. eng
Kinney MA, Warner ME, van Heerden JA, Horlocker TT, Young WF Jr, Schroeder DR, et al. Perianesthetic risks and outcomes of pheochromocytoma and paraganglioma resection. Anesth Analg. 2000;91(5):1118–23. PubMed PMID: 11049893. Epub 2000/10/26. eng
Kramer CK, Leitao CB, Azevedo MJ, Canani LH, Maia AL, Czepielewski M, et al. Degree of catecholamine hypersecretion is the most important determinant of intra-operative hemodynamic outcomes in pheochromocytoma. J Endocrinol Investig. 2009;32(3):234–7. PubMed PMID: 19542740. Epub 2009/06/23. eng
Chang RY, Lang BH, Wong KP, Lo CY. High pre-operative urinary norepinephrine is an independent determinant of peri-operative hemodynamic instability in unilateral pheochromocytoma/paraganglioma removal. World J Surg. 2014;38(9):2317–23. PubMed PMID: 24782037. Epub 2014/05/02. eng
Namekawa T, Utsumi T, Kawamura K, Kamiya N, Imamoto T, Takiguchi T, et al. Clinical predictors of prolonged postresection hypotension after laparoscopic adrenalectomy for pheochromocytoma. Surgery. 2016;159(3):763–70. PubMed PMID: 26477475. Epub 2015/10/20. eng
Phitayakorn R, McHenry CR. Perioperative considerations in patients with adrenal tumors. J Surg Oncol. 2012;106(5):604–10. PubMed PMID: 22513507. Epub 2012/04/20. Eng
Challis BG, Casey RT, Simpson HL, Gurnell M. Is there an optimal preoperative management strategy for phaeochromocytoma/paraganglioma? Clin Endocrinol. 2017;86(2):163–7. PubMed PMID: 27696513. Epub 2016/10/25. eng
Brunaud L, Boutami M, Nguyen-Thi PL, Finnerty B, Germain A, Weryha G, et al. Both preoperative alpha and calcium channel blockade impact intraoperative hemodynamic stability similarly in the management of pheochromocytoma. Surgery. 2014;156(6):1410–7. discussion7-8. PubMed PMID: 25456922. Epub 2014/12/03. eng
Wachtel H, Kennedy EH, Zaheer S, Bartlett EK, Fishbein L, Roses RE, et al. Preoperative Metyrosine improves cardiovascular outcomes for patients undergoing surgery for Pheochromocytoma and Paraganglioma. Ann Surg Oncol. 2015;22(Suppl 3):S646–54. PubMed PMID: 26374407. Epub 2015/09/17. eng
Roizen A. Prospective randomized trial of four anesthetic techniques for resection of pheochromocytoma. Anesthesiology. 1982;57: A43.
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017 PubMed PMID: 28045707. Epub 2017/01/04. eng.
STANDARDS FOR BASIC ANESTHETIC MONITORING [Web Document]. http://www.asahq.org/quality-and-practice-management/standards-and-guidelines: American Society of Anesthesiologists; 2015 [updated October 28, 2015; cited 2017 2/6/2017].
Khan FA, Ullah H. Pharmacological agents for preventing morbidity associated with the haemodynamic response to tracheal intubation. Cochrane Database Syst Rev, 2013; July 03 (7):Cd004087. PubMed PMID: 23824697. Epub 2013/07/05. eng
Usubiaga JE, Wikinski JA, Usubiaga LE. Use of lidocaine and procaine in patients with pheochromocytoma. Anesth Analg. 1969;48(3):443–53. PubMed PMID: 5815109. Epub 1969/05/01. eng
Ebert TJ, Muzi M, Berens R, Goff D, Kampine JP. Sympathetic responses to induction of anesthesia in humans with propofol or etomidate. Anesthesiology. 1992;76(5):725–33. PubMed PMID: 1575340. Epub 1992/05/01. eng
Stoner TR Jr, Urbach KF. Cardiac arrhythmias associated with succinylcholine in a patient with pheochromocytoma. Anesthesiology. 1968;29(6):1228–9. PubMed PMID: 5726757. Epub 1968/11/01. eng
Joffe D, Robbins R, Benjamin A. Caesarean section and phaeochromocytoma resection in a patient with von Hippel Lindau disease. Can J Anaesth J Can d'anesthesie. 1993;40(9):870–4. PubMed PMID: 8403182. Epub 1993/09/01. eng
Tomulic K, Saric JP, Kocman B, Skrtic A, Filipcic NV, Acan I. Successful management of unsuspected retroperitoneal paraganglioma via the use of combined epidural and general anesthesia: a case report. J Med Case Rep. 2013;7:58. PubMed PMID: 23448279. Pubmed Central PMCID: PMC3599738. Epub 2013/03/02. eng
Nizamoglu A, Salihoglu Z, Bolayrl M. Effects of epidural-and-general anesthesia combined versus general anesthesia during laparoscopic adrenalectomy. Surg Laparosc Endosc Percutan Tech. 2011;21(5):372–9. PubMed PMID: 22002277. Epub 2011/10/18. eng
Luo A, Guo X, Yi J, Ren H, Huang Y, Ye T. Clinical features of pheochromocytoma and perioperative anesthetic management. Chin Med J. 2003;116(10):1527–31. PubMed PMID: 14570616. Epub 2003/10/23. eng
O’Riordan JA. Pheochromocytomas and anesthesia. Int Anesthesiol Clin. 1997;35(4):99–127. PubMed PMID: 9444533. Epub 1998/01/28. eng
Ebert TJ, Muzi M. Sympathetic hyperactivity during desflurane anesthesia in healthy volunteers. A comparison with isoflurane. Anesthesiology. 1993;79(3):444–53. PubMed PMID: 8363068. Epub 1993/09/01. eng
El-Galley R, Hammontree L, Urban D, Pierce A, Sakawi Y. Anesthesia for laparoscopic donor nephrectomy: is nitrous oxide contraindicated? J Urol. 2007;178(1):225–7. discussion 7. PubMed PMID: 17512015. Epub 2007/05/22. eng
Sun R, Jia WQ, Zhang P, Yang K, Tian JH, Ma B, et al. Nitrous oxide-based techniques versus nitrous oxide-free techniques for general anaesthesia. Cochrane Database Syst Rev. 2015; Nov 6 (11):Cd008984. PubMed PMID: 26545294. Epub 2015/11/07. eng
Breslin DS, Farling PA, Mirakhur RK. The use of remifentanil in the anaesthetic management of patients undergoing adrenalectomy: a report of three cases. Anaesthesia. 2003;58(4):358–62. PubMed PMID: 12648118. Epub 2003/03/22. Eng
Ali Erdogan M, Selim Ozkan A, Ozgul U, Colak Y, Ucar M. Dexmedetomidine, Remifentanil, and Sevoflurane in the perioperative Management of a Patient during a laparoscopic Pheochromocytoma resection. J Cardiothorac Vasc Anesth. 2015;29(6):e79–80. PubMed PMID: 26411814. Epub 2015/09/29. Eng
Hughes RE, Magovern GJ. The relationship between right atrial pressure and blood volume. AMA Arch Surg. 1959;79(2):238–43. PubMed PMID: 13669851. Epub 1959/08/01. eng
Wilson JN, Grow JB, Demong CV, Prevedel AE, Owens JC. Central venous pressure in optimal blood volume maintenance. Arch Surg (Chicago, Ill: 1960). 1962;85:563–78. PubMed PMID: 14001047. Epub 1962/10/01. eng
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172–8. PubMed PMID: 18628220. Epub 2008/07/17. eng
Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774–81. PubMed PMID: 23774337. Epub 2013/06/19. eng
Legrand G, Ruscio L, Benhamou D, Pelletier-Fleury N. Goal-directed fluid therapy guided by cardiac monitoring during high-risk abdominal surgery in adult patients: cost-effectiveness analysis of esophageal Doppler and arterial pulse pressure waveform analysis. Value Health J Int Soc Pharmacoeconomics Outcomes Res. 2015;18(5):605–13. PubMed PMID: 26297088. Epub 2015/08/25. eng
Hack H. Use of the esophageal Doppler machine to help guide the intraoperative management of two children with pheochromocytoma. Paediatr Anaesth. 2006;16(8):867–76. PubMed PMID: 16884470. Epub 2006/08/04. eng
Kinney MA, Narr BJ, Warner MA. Perioperative management of pheochromocytoma. J Cardiothorac Vasc Anesth. 2002;16(3):359–69. PubMed PMID: 12073213. Epub 2002/06/20. eng
Subramaniam R. Pheochromocytoma – current concepts in diagnosis and management. Trends Anaesth Crit Care. 2011;1(2):104–10.
Friederich JA, Butterworth JF. Sodium nitroprusside: twenty years and counting. Anesth Analg. 1995;81(1):152–62. PubMed PMID: 7598246. Epub 1995/07/01. eng
Boden WE, Padala SK, Cabral KP, Buschmann IR, Sidhu MS. Role of short-acting nitroglycerin in the management of ischemic heart disease. Drug Des Devel Ther. 2015;9:4793–805. PubMed PMID: 26316714. Pubmed Central PMCID: PMC4548722. Epub 2015/09/01. eng
Lord MS, Augoustides JG. Perioperative management of pheochromocytoma: focus on magnesium, clevidipine, and vasopressin. J Cardiothorac Vasc Anesth. 2012;26(3):526–31. PubMed PMID: 22361482. Epub 2012/03/01. Eng
Kwon SY, Lee KS, Lee JN, Ha YS, Choi SH, Kim HT, et al. Risk factors for hypertensive attack during pheochromocytoma resection. Investig Clin Urol. 2016;57(3):184–90. PubMed PMID: 27194549. Pubmed Central PMCID: PMC4869566. Epub 2016/05/20. Eng
Kiernan CM, Du L, Chen X, Broome JT, Shi C, Peters MF, et al. Predictors of hemodynamic instability during surgery for pheochromocytoma. Ann Surg Oncol. 2014;21(12):3865–71. PubMed PMID: 24939623. Pubmed Central PMCID: PMC4192065. Epub 2014/06/19. Eng
Treschan TA, Peters J. The vasopressin system: physiology and clinical strategies. Anesthesiology. 2006;105(3):599–612. quiz 39-40. PubMed PMID: 16931995. Epub 2006/08/26. eng
Roth JV. Use of vasopressin bolus and infusion to treat catecholamine-resistant hypotension during pheochromocytoma resection. Anesthesiology. 2007;106(4):883–4. PubMed PMID: 17413940. Epub 2007/04/07. eng
Tan SG, Koay CK, Chan ST. The use of vasopressin to treat catecholamine-resistant hypotension after phaeochromocytoma removal. Anaesth Intensive Care. 2002;30(4):477–80. PubMed PMID: 12180588. Epub 2002/08/16. eng
Brunaud L, Nguyen-Thi PL, Mirallie E, Raffaelli M, Vriens M, Theveniaud PE, et al. Predictive factors for postoperative morbidity after laparoscopic adrenalectomy for pheochromocytoma: a multicenter retrospective analysis in 225 patients. Surg Endosc. 2016;30(3):1051–9. PubMed PMID: 26092019. Epub 2015/06/21. Eng
Srougi V, Chambo JL, Tanno FY, Soares IS, Almeida MQ, Pereira MA, et al. Presentation and surgery outcomes in elderly with pheocromocytoma: a comparative analysis with young patients. Int Braz J Urol Off J Braz Soc Urol. 2016;42(4):671–7. PubMed PMID: 27564276. Pubmed Central PMCID: PMC5006761. Epub 2016/08/27. eng
Dugas G, Fuller J, Singh S, Watson J. Pheochromocytoma and pregnancy: a case report and review of anesthetic management. Can J Anaesth J Can d'anesthesie. 2004;51(2):134–8. PubMed PMID: 14766689. Epub 2004/02/10. Eng
Jayatilaka G, Abayadeera A, Wijayaratna C, Senanayake H, Wijayaratna M. Phaeochromocytoma during pregnancy: anaesthetic management for a caesarean section combined with bilateral adrenalectomy. Ceylon Med J. 2013;58(4):173–4. PubMed PMID: 24385061. Epub 2014/01/05. Eng
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Stojiljkovic, L. (2018). Anesthetic Management of Pheochromocytoma and Paraganglioma. In: Landsberg, L. (eds) Pheochromocytomas, Paragangliomas and Disorders of the Sympathoadrenal System. Contemporary Endocrinology. Humana Press, Cham. https://doi.org/10.1007/978-3-319-77048-2_9
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