Anesthesia for the adult with pheochromocytoma
- Shamsuddin Akhtar, MD
Shamsuddin Akhtar, MD
- Associate Professor
- Yale School of Medicine
Pheochromocytomas are neoplasms of chromaffin tissue that synthesize catecholamines. Pheochromocytoma is a rare disorder that presents challenges for the anesthesiologist. By some estimates, 25 to 50 percent of hospital deaths of patients with unmanaged or unknown pheochromocytoma occur during induction of anesthesia or during operative procedures for other conditions . Since treatment of pheochromocytoma almost always includes surgical resection, most of these patients will require anesthesia.
Paragangliomas are neuroendocrine tumors that arise from the extra-adrenal autonomic ganglia and are indistinguishable from pheochromocytomas at the cellular level. They can secrete catecholamines and present clinically like pheochromocytomas, so the concerns for anesthesia for patients with paragangliomas are the same.
This topic will discuss the preoperative evaluation, intraoperative management, and postoperative care of patients who will undergo resection of pheochromocytoma. The diagnosis and presentation, epidemiology, and genetics of pheochromocytoma, as well as medical optimization prior to surgery, pheochromocytoma during pregnancy, and nonsurgical treatment of pheochromocytoma, are discussed separately. (See "Clinical presentation and diagnosis of pheochromocytoma" and "Treatment of pheochromocytoma in adults" and "Paraganglioma and pheochromocytoma: Management of malignant disease" and "Pheochromocytoma in genetic disorders" and "Treatment of pheochromocytoma in adults", section on 'Medical preparation for surgery' and "Clinical presentation and diagnosis of pheochromocytoma", section on 'Pheochromocytoma in pregnancy'.)
PERIANESTHETIC RISKS AND OUTCOMES
Many patients who undergo pheochromocytoma resection exhibit labile blood pressure (BP), arrhythmias, and tachycardia during and after surgery, though most can be managed without lasting morbidity or mortality. Because of the rarity of pheochromocytoma, most data on the anesthetic management and perioperative outcomes have been reported in small case series that spanned many years. The following observational studies illustrate the complications seen in patients with known pheochromocytoma who present for resection:
●An observational study of 108 resections performed at a single institution reported no intraoperative deaths, two intraoperative arrhythmias (which were not defined), and one postoperative stroke .
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- PERIANESTHETIC RISKS AND OUTCOMES
- PREOPERATIVE EVALUATION
- Timing and goals
- Clinical assessment
- - End organ damage
- - Preoperative medical therapy
- Goals of therapy
- Impact on intraoperative management
- Preoperative testing
- SURGICAL APPROACH
- STAGES OF SURGERY
- Phase I
- Phase II
- ANESTHESIA MANAGEMENT
- Choice of anesthetic technique
- Monitoring and venous access
- Induction and maintenance of anesthesia
- Medications to avoid
- TREATMENT OF INTRAOPERATIVE HEMODYNAMIC CHANGES
- Treatment of hypertension and arrhythmias
- - Antihypertensive medications
- - Antiarrhythmics
- Treatment of hypotension
- OUR ANESTHETIC STRATEGY
- POSTOPERATIVE CARE
- SUMMARY AND RECOMMENDATIONS