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S5 - Advanced Patho > Pheo Management Article > Flashcards

Pheo Management Article Flashcards

1
Q

What has been the mainstay of preoperative preparation for pheo for 60 years?

A

Alpha blockade

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2
Q

Goals to meet for pheo patient prior to surgical excision (4)

A
  1. No in-hospital BP >160/90 mmHg for 24 h prior to surgery
  2. No orthostatic hypotension with BP <80/45 mmHg
  3. No ST or T wave changes for 1-week prior to surgery
  4. No more than 5 PVCs per minute.
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3
Q

Implications if 4 criteria not met prior to surgical excision of pheo

A

Poorer outcomes

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4
Q

When is alpha blocker typically begun prior to surgical excision of pheo?

Benefits?

A

10-14 days prior

Benefits:

  • Blood pressure control
  • Expands highly contracted intravascular volume
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5
Q

High risk pheo patients

A
  • Catecholamine cardiomyopathy
  • MI
  • Patients with refractory hypertension
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6
Q

Why should beta-blockade only be used after alpha blockade?

A

Could cause catastrophic hypertensive crisis that would ensue with unopposed alpha receptor stimulation

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7
Q

Besides alpha and beta blockers, what drugs are useful in periop pheo patient due to easier titration and less orthostatic hypotension?

A

Dihydropyridine calcium channel blockers

(nicardipine)

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8
Q

What type of consult is necessary for pheo excision?

What test should be included?

A

CV

Echo

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9
Q

What is catecholamine cardiomyopathy?

A

A form of myocardial stunning from the toxic effects of catecholamines on the myocardium

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10
Q

What approach for pheo excision is preffered?

A

Laparoscopic

(Now robotic also)

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11
Q

When are open procedures typically used for pheo?

A

Larger masses and extra-adrenal tumors with limited access

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12
Q

Can any old rinky dink hospital perform pheo excision?

A

Recommended to be performed at centers that routinely perform this surgery

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13
Q

What makes an anesthetic so difficult for pheo patient?

A

Catecholamine surges
Especially during:

  • Laryngoscopy
  • Peritoneal insufflation
  • Surgical stimulation
  • Tumor handling
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14
Q

important type of med to give to a preop pheo

A

anxiolytic

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15
Q

What type of additional monitoring is an absolute indication in all pheocromocytoma patients prior to anesthetic induction?

A

Invasive arterial monitoring via arterial catheter

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16
Q

T/F you have to have a CVL for pheo patient prior to induction

A

False

A large bore IV peripheral IV is necessary for induction

17
Q

Morning of surgery should your patient take their short-active alpha 1 blocker?

What about long acting?

A
  • Short acting can be administered morning of procedure
  • Long acting agents such as phenoxybenxamine and doxazosin are usually withheld 12-24 hours prior to operation
18
Q

What drugs should you have on hand for pheo case?

A
  • Nitroglycerine
  • Sodium nitroprusside
  • Nicardipine
  • Diltiazem
  • Esmolol for HR control
  • Magnesium sulfate
  • Norepinephrine
  • Vasopressin
19
Q

What additional drugs should you have on hand if patient has catecholamine cardiomyopathy on top of pheo?

Right ventricular disfunction?

A
  • Inotropes (Epinephrine, Dobutamine)- CC
  • Milrinone- RV dysfunction
20
Q

What should you have on hand for rapid volume expansion with pheo patient?

A
  • Colloids
  • Plasma expanders
  • Blood products
21
Q

What other invasive lines/monitoring is used in pheo case besides art line?

A
  • central venous cannulation for fluid management and delivery of vasoactive agents
  • PA catheters
  • TEE
  • Consider rapid transfusion systems
22
Q

Anesthetic induction for pheo is one of the most critical portions of the procedure..

What drugs are used and what drugs are avoided?

A
  • Propofol and etomidate commonly used
  • Ketamine usually avoided
  • Avoid histamine releasing drugs
23
Q

NMB considerations in pheo patient

A

Succinylcholine has potential to cause catecholamine surges

Vec and roc widely used

24
Q

Drugs used to attenuate pressor response of laryngoscopy

A
  • Fentanyl in small doses
  • IV lidocaine
  • Esmolol 0.5 mg/kg bolus
  • Nitroglycerine, nicardipine, or sodium nitroprusside as needed
25
Q

Mainstay of anesthetic for pheo resection

A

Inhaled agents

isoflurane and sevo extensively used

Avoid desflurane due to significant sympathetic stimulation

26
Q

What causes hypertension in pheo procedure?

A
  • Positioning
  • Skin incision
  • Intubation
27
Q

Why does tumor manipulation cause a far more dramatic pressor response?

A

Directly related to significant increases in plasma levels of norepinephrine and epinephrine

Associated with severe hemodynamic instability

28
Q

How to treat acute hemodynamic crisis with pheo

A
  • Deepen anesthetic depth
  • Rapidly administer direct arterial vasodilators
  • Nipride being key drug in conjunction with nitroglycerine to reduce preload
  • Mag sulfate
29
Q

T/F hypoglycemia common in pheo patient

A

False

Hyperglycemia is common

30
Q

What may occur following ligation of tumor?

A

Sudden hypotension

31
Q

What can help prevent hypotension after tumor ligation?

A

Large volume fluid bolus administration

Not uncommone for anesthesiologist to administer 2-3 L of fluid crystalloid and colloid prior to ligation

32
Q

Good drug for refractory hypotension in a pheo pt

A

Vasopressin

33
Q

What drug may be considered for hemodynamic rescue in pheo pt?

A

IV methylene blue

34
Q

indication of the need for postop ventilation in pheo pt

A

persistent hemodynamic instability

35
Q

What must you rule out in drowsy, unresponsive pheo patient?

A

Electrolyte and endocrine abnormalities

Hypoglycmia and hyponatremia

36
Q

In the vast majority of patients who undergo laparoscopic tumor resections, are post-op issues common?

A

Nope, minimal

37
Q

What may persistant hypotension indicate following pheo excision?

A
  • Surgical bleeding
  • Inadequate fluid resuscitation
  • Residual anesthetic-induced vasodilation
38
Q

Does hypertension always resolve after pheo resection?

A

No

May persist in 50 percents of patients

39
Q

What does successful pheo management require?

A
  • Careful preoperative optimization
  • Meticulous intra-op planning
  • Hemodynamic management

S5 - Advanced Patho (6 decks)

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