Perioperative management of pheochromocytoma.

Perioperative Management of Pheochromocytoma

The purpose of this structured, evidence-based, clinical update was to determine if rapid sequence induction is a safe or effective technique to decrease the risk of aspiration or other complications of airway management. In June 2006 a structured search of medline from 1966 to present using OVID software was undertaken with the assistance of a reference librarian. Medical subject headings and text words describing rapid sequence induction or intubation (RSI), crash induction or intubation, cricoid pressure and emergency airway intubation were employed. OVID’s therapy (sensitivity) algorithm was used to maximize the detection of randomized trials while excluding non-randomized research. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search. A total of 184 clinical trials were identified of which 163 were randomized controlled trials (RCTs). Of these clinical trials, 126 evaluated different drug regimens with 114 being RCTs. Only 21 clinical trials evaluated non-pharmacologic aspects of the RSI with 18 RCTs identified. A parallel search found 52 trials evaluating cricoid pressure (outside of the context of an RSI technique) with 44 classified as RCTs. Definitive outcomes such as prevention of aspiration and mortality benefit could not be evaluated from the trials. Likewise, the impact on adverse outcomes of the different components of RSI could not be ascertained. An absence of evidence from RCTs suggests that the decision to use RSI during management can neither be supported nor discouraged on the basis of quality evidence.

/pdf/no-evidence-for-decreased-incidence-of-aspiration-after-2hnq4pzzg0.pdf

No evidence for decreased incidence of aspiration after rapid sequence induction

We investigated hemodynamics and plasma catecholamine concentrations in eight consecutive patients undergoing laparoscopic adrenalectomy for suspected pheochromocytoma.The same anesthesia protocol was used in all patients: a continuous infusion of sufentanil 0.5 [micro sign]g [center dot] kg-1 [cent

Hemodynamic Changes and Catecholamine Release During Laparoscopic Adrenalectomy for Pheochromocytoma

Background. Laparoscopic surgery for phaeochromocytoma can cause excessive catecholamine release with severe hypertension and sinus tachycardia. I.V. calcium antagonists may be used to prevent increases in blood pressure during phaeochromocytoma resection. We investigated the effects of perioperative a1 adrenergic block with urapidil on intraoperative haemodynamic events. The aim was to block the a1 adrenergic receptors before any acute catecholamine release, to prevent any severe rise in blood pressure. Methods. Eighteen patients with a phaeochromocytoma received a continuous i.v. infusion of urapidil 10‐15 mg h ‐1 for 3 days before surgery and until the adrenal gland had been removed. Plasma catecholamine concentrations were measured before surgery, after induction of anaesthesia, at the end of pneumoperitoneal insufflation, during gland manipulation, after gland resection, and in the recovery room after extubation. Arterial pressure was recorded concomitantly. Hypertensive events were treated with boluses of nicardipine with or without esmolol. Results. All patients had the adrenal tumour removed without any severe rise in blood pressure or other complication. Creation of a pneumoperitoneum and adrenal gland manipulation induced significant catecholamine release associated with hypertension in 6 and 12 patients, respectively. No correlation was found between hypertensive events and plasma catecholamine levels suggesting a1 receptor block with urapidil is efficacious. Conclusions. Perioperative a1 block using i.v. urapidil is a safe and efficient alternative during surgical management of phaeochromocytoma. Br J Anaesth 2004; 92: 512‐17

Effects of perioperative α1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma

We compared the effect of thiopentone and ketamine on intubating conditions after rocuronium 0.6 mg.kg-1 in two groups of patients (n = 16 each), aged 21-44 years, undergoing elective surgery. Premedication consisted of alprazolam 1 mg by mouth 1 h before surgery. All patients received midazolam 2 mg intravenously 2 min before intravenous administration of thiopentone 5 mg.kg-1 or ketamine 2.5 mg.kg-1. Muscle relaxation was provided by rocuronium 0.6 mg.kg-1. One minute after rocuronium administration, tracheal intubation was performed within 15 s by a skilled anaesthetist blinded to the treatment group assignment. Intubating conditions were graded as excellent, good, fair or poor on the basis of jaw relaxation, position of vocal cords and diaphragmatic response. Neuromuscular transmission was assessed at the adductor pollicis muscle using a TOF-GUARD monitor. Excellent and good intubating conditions were obtained in 100% of patients in the ketamine group and in 50% of patients in the thiopentone group (p = 0.002). Jaw relaxation was similar in both groups but vocal cord conditions were better and the diaphragmatic response less marked in the ketamine group compared with the thiopentone group (p = 0.002). The degree of neuromuscular block [% decrease of T1, mean (SD)] at the time of intubation was similar: 51.8 (25)% (ketamine group) and 54.3 (23.1)% (thiopentone group). We conclude that ketamine 2.5 mg.kg-1 provides better intubating conditions than thiopentone 5 mg.kg-1 1 min after administration of rocuronium 0.6 mg.kg-1.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1046/j.1365-2044.1999.00703.x

Influence of induction of anaesthesia on intubating conditions one minute after rocuronium administration: comparison of ketamine and thiopentone

Until now, the need for wide exposure and nonmanipulative dissection of pheochromocytoma has dictated the use of a large intraperitoneal transabdominal approach, which unfortunately results in a significant incidence of morbidity. A unilateral retroperitoneal approach guided by the refinements of new imaging techniques is less invasive but is associated with a small risk of incomplete cure. In one case report, we tested the hypothesis that laparoscopic surgery could combine the beneficial effects of both operative strategies without their respective side effects. We concluded that a laparoscopic approach combined with exclusive intraoperative infusion of nicardipine, a calcium-channel blocker, can be used to surgically remove pheochromocytoma under stable hemodynamic conditions. This provides better exposure of the anatomical structures than open surgery and allows a visual exploration of the entire abdominal cavity to exclude tumor multicentricity or ectopic sites in the case of inconclusive preoperative imaging investigations. Moreover, conversion to open surgery is always possible if needed.

Laparoscopic removal of pheochromocytoma Why? When? and Who? (Reflections on one case report)

Impact of 6 % hydroxyethyl starch (HES) 130/0.4 on the correlation between standard laboratory tests and thromboelastography (TEG®) after cardiopulmonary bypass

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Hemodynamic Changes and Catecholamine Release During Laparoscopic Adrenalectomy for Pheochromocytoma

Influence of induction of anaesthesia on intubating conditions one minute after rocuronium administration: comparison of ketamine and thiopentone

Laparoscopic removal of pheochromocytoma Why? When? and Who? (Reflections on one case report)

Impact of 6 % hydroxyethyl starch (HES) 130/0.4 on the correlation between standard laboratory tests and thromboelastography (TEG®) after cardiopulmonary bypass