Journal: J Cardiothorac Vasc Anesth 21(6):858-862, 2007
Reprint: Department of Anaesthesia, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands WA 6009, Australia (HJ Holldack, MBBS, FANZCA)
Faculty Disclosure: Abstracted by T. Tilton, who has nothing to disclose.
Because the diagnosis of pheochromocytoma is often difficult, with 35-45% occurring at autopsy, patients may present for surgery undiagnosed. A case report is made of an 87-yr-old female, 63 kg, presenting for wide re-excision of a melanoma on her face with a need for skin-grafting. Pertinent history included long-term hypertension (HTN), well-controlled with lisinopril; angina pectoris (none for 2 years), and medications of haloperidol, for anxiety, omeprazole, atorvastatin, and pilocarpine and timolol eye drops. Physical examination showed blood pressure (BP) of 140/80 mmHg, heart rate (HR) 68 bpm, and normal blood count, electrolytes and electrocardiogram.
On the day of surgery, the patient's BP was 220/110 mmHg and HR 64 beats/min, with the patient stating she was anxious; lisinopril had been taken that morning. Haloperidol had not been taken for at least 24 hours. She reported that regular BP readings had been normal when obtained by her family physician, leading the author to conclude that the HTN was due to anxiety and the surgery minor enough to proceed. The patient received reassurance, midazolam 1 mg and fentanyl 25 mcg leading to BP of 190/90 mmHg. An arterial catheter was placed to closely monitor BP. It was felt that induction would further reduce the BP, so no antihypertensive medications were given. Fentanyl 3 mcg/kg was planned as part of the induction, which consisted of midazolam 1 mg, fentanyl 175 mcg, propofol 60 mg, titrated to loss of eyelash reflex.
Mask ventilation with sevoflurane 2% was adminis¬tered for a few breaths before rocuronium 40 mg was given. The patient's BP then increased to 200 mmHg systolic, which was treated with propofol 140 mg but it rose to 330/180 mmHg with HR 70-120 and runs of supraventricular tachycardia up 160 bpm. No sweat¬ing or skin color change was noted. Nitro¬glycerin (NTG) 100 mcg bolus and 2 additional boluses of 100 mcg and 300 mcg were given followed by an infusion. The patient's BP decreased to 150/70 mmHg; esmolol was administered in boluses to a total of 100 mg to reduce HR, and clonidine 150 mcg was given to reduce sympathetic nervous system tone. Intubation was then accom¬plished without increasing BP or HR. NTG was discontinued 25 min after induction and the proce¬dure was cancelled. The differential diagnoses con¬sidered were: drug error (excluded by checking syringes), malpositioning of transducer (excluded), pheochromocytoma, neuro¬genic HTN (eg., raised intracranial pressure, stroke, subarachnoid hemor¬rhage, or brainstem pathology), and malignant hyper¬thermia/thyrotoxic crisis/carci¬noid syndrome (less likely).
The patient, anesthetized and intubated, was taken for computed tomography (CT): head CT was unremark¬able but abdominal CT showed a right suprarenal mass supporting a diagnosis of pheochromocytoma. Metaraminol 0.5 mg was given for hypotension during the scan but further NTG was required after the scan and during extubation.
The patient was taken to the intensive care unit where her BP was stable at 150/85 mmHg without NTG. Pheochromocytoma was confirmed with laboratory testing and treatment was initiated. Review of the patient’s history revealed two very isolated high BP readings and intermittent dizzy spells with no other symptoms. Laparoscopic adrenalectomy was per¬formed 3 weeks later, uneventfully.
It is concluded that while pheochromocytoma is a rare tumor, it may present unexpectedly during anes¬thesia. Prompt diagnosis and treatment are the keys to reduce mortality. Any patient with grossly exag¬gerated and unexplained HTN and tachycardia during anesthesia should be evaluated for pheochromo¬cytoma. |
