Pheo Management Article Flashcards
What has been the mainstay of preoperative preparation for pheo for 60 years?
Alpha blockade
Goals to meet for pheo patient prior to surgical excision (4)
- No in-hospital BP >160/90 mmHg for 24 h prior to surgery
- No orthostatic hypotension with BP <80/45 mmHg
- No ST or T wave changes for 1-week prior to surgery
- No more than 5 PVCs per minute.
Implications if 4 criteria not met prior to surgical excision of pheo
Poorer outcomes
When is alpha blocker typically begun prior to surgical excision of pheo?
Benefits?
10-14 days prior
Benefits:
- Blood pressure control
- Expands highly contracted intravascular volume
High risk pheo patients
- Catecholamine cardiomyopathy
- MI
- Patients with refractory hypertension
Why should beta-blockade only be used after alpha blockade?
Could cause catastrophic hypertensive crisis that would ensue with unopposed alpha receptor stimulation
Besides alpha and beta blockers, what drugs are useful in periop pheo patient due to easier titration and less orthostatic hypotension?
Dihydropyridine calcium channel blockers
(nicardipine)
What type of consult is necessary for pheo excision?
What test should be included?
CV
Echo
What is catecholamine cardiomyopathy?
A form of myocardial stunning from the toxic effects of catecholamines on the myocardium
What approach for pheo excision is preffered?
Laparoscopic
(Now robotic also)
When are open procedures typically used for pheo?
Larger masses and extra-adrenal tumors with limited access
Can any old rinky dink hospital perform pheo excision?
Recommended to be performed at centers that routinely perform this surgery
What makes an anesthetic so difficult for pheo patient?
Catecholamine surges
Especially during:
- Laryngoscopy
- Peritoneal insufflation
- Surgical stimulation
- Tumor handling
important type of med to give to a preop pheo
anxiolytic
What type of additional monitoring is an absolute indication in all pheocromocytoma patients prior to anesthetic induction?
Invasive arterial monitoring via arterial catheter
T/F you have to have a CVL for pheo patient prior to induction
False
A large bore IV peripheral IV is necessary for induction
Morning of surgery should your patient take their short-active alpha 1 blocker?
What about long acting?
- 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
What drugs should you have on hand for pheo case?
- Nitroglycerine
- Sodium nitroprusside
- Nicardipine
- Diltiazem
- Esmolol for HR control
- Magnesium sulfate
- Norepinephrine
- Vasopressin
What additional drugs should you have on hand if patient has catecholamine cardiomyopathy on top of pheo?
Right ventricular disfunction?
- Inotropes (Epinephrine, Dobutamine)- CC
- Milrinone- RV dysfunction
What should you have on hand for rapid volume expansion with pheo patient?
- Colloids
- Plasma expanders
- Blood products
What other invasive lines/monitoring is used in pheo case besides art line?
- central venous cannulation for fluid management and delivery of vasoactive agents
- PA catheters
- TEE
- Consider rapid transfusion systems
Anesthetic induction for pheo is one of the most critical portions of the procedure..
What drugs are used and what drugs are avoided?
- Propofol and etomidate commonly used
- Ketamine usually avoided
- Avoid histamine releasing drugs
NMB considerations in pheo patient
Succinylcholine has potential to cause catecholamine surges
Vec and roc widely used
Drugs used to attenuate pressor response of laryngoscopy
- Fentanyl in small doses
- IV lidocaine
- Esmolol 0.5 mg/kg bolus
- Nitroglycerine, nicardipine, or sodium nitroprusside as needed
Mainstay of anesthetic for pheo resection
Inhaled agents
isoflurane and sevo extensively used
Avoid desflurane due to significant sympathetic stimulation
What causes hypertension in pheo procedure?
- Positioning
- Skin incision
- Intubation
Why does tumor manipulation cause a far more dramatic pressor response?
Directly related to significant increases in plasma levels of norepinephrine and epinephrine
Associated with severe hemodynamic instability
How to treat acute hemodynamic crisis with pheo
- Deepen anesthetic depth
- Rapidly administer direct arterial vasodilators
- Nipride being key drug in conjunction with nitroglycerine to reduce preload
- Mag sulfate
T/F hypoglycemia common in pheo patient
False
Hyperglycemia is common
What may occur following ligation of tumor?
Sudden hypotension
What can help prevent hypotension after tumor ligation?
Large volume fluid bolus administration
Not uncommone for anesthesiologist to administer 2-3 L of fluid crystalloid and colloid prior to ligation
Good drug for refractory hypotension in a pheo pt
Vasopressin
What drug may be considered for hemodynamic rescue in pheo pt?
IV methylene blue
indication of the need for postop ventilation in pheo pt
persistent hemodynamic instability
What must you rule out in drowsy, unresponsive pheo patient?
Electrolyte and endocrine abnormalities
Hypoglycmia and hyponatremia
In the vast majority of patients who undergo laparoscopic tumor resections, are post-op issues common?
Nope, minimal
What may persistant hypotension indicate following pheo excision?
- Surgical bleeding
- Inadequate fluid resuscitation
- Residual anesthetic-induced vasodilation
Does hypertension always resolve after pheo resection?
No
May persist in 50 percents of patients
What does successful pheo management require?
- Careful preoperative optimization
- Meticulous intra-op planning
- Hemodynamic management
