Pheochromocytoma Resection
Patient phenotype
Catecholamine-secreting adrenal (or extra-adrenal/paraganglioma) tumor. Classic triad: episodic headache + palpitations + diaphoresis with paroxysmal hypertension. Often misdiagnosed for years. May present with stroke, MI, cardiomyopathy, or as incidentaloma. Often associated with MEN2, VHL, NF1.
Procedure
Laparoscopic adrenalectomy preferred. ~2-4 hours. Lateral decubitus position. Surgical manipulation = catecholamine surge. After tumor vein ligated, blood pressure crashes (catecholamine washout + chronic alpha-blockade-induced volume depletion).
Anesthetic plan
GETA with full invasive monitoring. Pharmacologically prepared patient (alpha-blockade 10-14 days, beta added after, generous salt + fluid loading). Drugs that release histamine (morphine, atracurium) avoided. Drugs that stimulate sympathetics (ketamine, ephedrine) avoided. Vasopressor + vasodilator infusions ready before induction.
Setup
- ·A-line PRE-induction (mandatory)
- ·Central line (CVC) — fluids + pressors
- ·2× large-bore PIVs
- ·Phenylephrine, norepinephrine, vasopressin infusions ready
- ·Nitroprusside or nicardipine + esmolol infusions ready (for hypertensive crisis)
- ·Magnesium 2g loaded + infusion ready (helps blunt catecholamine surge)
- ·Forced air warmer + temp probe
- ·OR table with lateral decubitus capability
Biggest concerns by phase
Adequacy of alpha-blockade
Phenoxybenzamine (or doxazosin) 10-14 days preop. Roizen criteria: BP ≤ 165/90 24 h pre-op, no orthostatic < 80/45, normal ECG (no ST changes for ≥ 1 wk), ≤ 5 PVCs/min. Beta-blockade ONLY after alpha — beta first → unopposed alpha → hypertensive crisis.
Volume status — chronic catecholamine vasoconstriction = volume-depleted
Alpha-blockade unmasks volume depletion. High-salt diet + 1-2 L IV fluid bolus night before + morning of surgery. Without this, hypotension after tumor removal is catastrophic.
Avoid catecholamine release
Smooth induction is mandatory. Avoid: ketamine, ephedrine, morphine (histamine), atracurium (histamine), succinylcholine (fasciculation → catecholamine release — controversial). Use: propofol, fentanyl/sufentanil, rocuronium or cisatracurium. Generous opioid + lidocaine before laryngoscopy. Mag 2-4 g pre-induction blunts response.
Hypertensive crisis with tumor manipulation
Each tumor handling = sudden BP spike (often > 250 systolic). Treatment: deepen anesthesia, nitroprusside or nicardipine + esmolol bolus, magnesium. Communicate with surgeon — 'pause manipulation' often most effective.
Hypotension after tumor vein ligation
Within minutes of tumor vein clamp: catecholamine source gone, residual alpha-blockade + volume depletion = severe hypotension. Aggressive fluid resuscitation + norepinephrine + vasopressin. May need pressor support hours-days postop. NEVER give pressors before tumor isolated unless dire.
Hypoglycemia + adrenal insufficiency
Catecholamines were suppressing insulin; once gone → hypoglycemia common (check q1h x 24h). If bilateral adrenalectomy → adrenal insufficiency, stress-dose steroids (hydrocortisone 100 mg q8h). ICU monitoring 24 h.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-year-old with documented pheochromocytoma, on phenoxybenzamine 30 mg BID + propranolol 20 mg TID for 3 weeks. BP supine 130/85, standing 105/70 with mild lightheadedness. HR 70. Day of surgery — ready to proceed?
What an examiner probes for
- ▹Confirms Roizen criteria adequately met
- ▹Recognizes orthostatic drop is expected goal of alpha-blockade
- ▹Verifies preop volume loading (high-salt diet, IV fluid)
- ▹Reviews drugs to avoid + emergency drugs available
- ▹Ensures A-line + central access pre-induction
Surgeon manipulates the tumor. BP spikes from 140/85 to 260/140. HR 130 with frequent PVCs. ETCO2 stable at 35. What's happening + your immediate response?
What an examiner probes for
- ▹Recognizes catecholamine surge from manipulation
- ▹Asks surgeon to pause manipulation
- ▹Deepens anesthesia + delivers nitroprusside or nicardipine bolus
- ▹Adds esmolol for tachycardia (only after vasodilator)
- ▹Considers Mg bolus, lidocaine for PVCs
Sources
- Miller's Ch 35 + 71
- Stoelting/Hines Ch 24
- Endocrine Society Pheo Guidelines 2014
Anatomy reference
Sourced reference images. 4 matches for "adrenal kidney endocrine".
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