Ursula Chohan, Fazal H Khan.
Anaesthetic management of a patient with Pheochromocytoma and uncontrolled blood pressure.
J Coll Physicians Surg Pak Jan ;9(5):236-8.

Anaesthetic management of phaeochromocytoma includes pre-operative preparation, intraoperative control and avoidance of drugs that cause hypotension or hypertension. A case of 46-year old male, with phaeochromocytoma is presented here highlighting issues in anaesthetic management.

CASE REPORT: A 46 years old male, diagnosed case of phaeochromocytoma with paroxysmal hypertension, was admitted to control his recent symptom of breathlessness. He is an insulin dependent diebetic, and a heavy smoker. He also had one episode of chest pain, which radiated to the left arm, about 6 months ago. The urinary catecholamines were 2256 mg/24 hours (range 10-270), urine VMA was 4340mg/24 hours (range 1.9-9.8), serum cortisol was 23.9 (3.25) and S.DHEA S04 was 35.8 (range 80-560). The patient had a regular follow up, and repeat investigations after one month of treatment showed an ejection fraction of 43%. Moderate fluctuations in the control of blood pressure were observed and patient was admitted to the intensive care unit for further management of fluctuating blood pressure prior to the surgical removal of the tumour. On the morning of surgery, the patient was premedicated with morphine 10mg intramuscular, midazolam 7.5 mg orally alongwith his antihypertensive medications. This resulted in a drop of blood pressure to 80/50 mmHg. Following a fluid bolus of 500 ml, the B.P. came up to 90/60 mmHg. Patient was shifted to O.R. for monitoring. Arterial line was established in the left radial artery, for invasive blood pressure monitoring. Blood pressure ranged between 85-95/55-60 mmHg. A 1000 ml of fluid was infused, that resulted in blood pressure of 100/60 mmHg but patient developed tachycardia, with a heart rate of 120-130/min. A swan ganz catheter was inserted at this stage. Initial central venous pressure was 3 cm of water, for which 2.5L fluid was given and central venous pressure came upto 6 cm of water, cardiac out put was 6.5 L and systemic vascular resistance was 550. Nordarenaline infusion at the rate of 0.02 ug/kg/min was started to improve the systemic vascular resistance and thereafter blood pressure rose to 120-130/65-75, heart rate 90/min, central venous pressure came upto 10 cm of water, cardiac out put was 10L/min and the systemic vascular resistance was 650. The Noradrenaline infusion was stopped before induction. Induction of anaestheia was carried out with midazolam, thiopentone, vecuronium, and maintained on isoflurane, vecuronium and morphine. Intra operatively patient remained stable until the manipulation of tumour when the B.P. shot up from 120/70 to 200-300/100-160 mm of Hg. sodium nitroprusside (0.3-hug/kg/min) infusion was started to control the blood pressure. The resection time was 75 minutes. Following resection of the tumor the blood pressure dropped to 90/60 mm Hg. Nor adrenaline infusion was restarted at 0.04-O.lug/kg/min and when the blood pressure reached the base line, dose was decreased to 0.02ug/kg/min. After completion of surgery, the patient was extubated and shifted to the ICU with noradrenaline infused at a rate of 0.03O.lug/kg/min.

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