Phaeochromocytoma

 

Main things:

·        Hypertensive crisis is a medical (not surgical) emergency

·        Pre-op alpha blockers are critical

 

Disease:

Presentation

·          Hx: headache, palpitations, sweating

·          Ex: tachycardia, hypertension

·          Ix: catechols in urine and plasma, tumour on CT A/P

Complications

·          Hypertensive crisis

·          Tachyarrhythmia

·          Cardiomyopathy

·          Diabetes

·          Electrolyte disturbance

Patterns

·          50% incidentaloma

·          30% extra-adrenal

·          30% malignant

·          30% familial

·          10% bilateral

·          10% normotensive

 

Pre-op issues:

Goals

·          Normal blood pressure (<160/90)

·          Normal blood volume

·          Normal rate and rhythm

·          No ischaemia on ECG

·          Stable complications

Monitoring

·          Vitals: HR, BP

·          Cardiac: ECG, TTE

·          Metabolic: BSL, UEC

Treatment

·          BP: phenoxybenzamine (stop 1-2 days pre-op)

·          BV: salt and water

·          R&R: pure B1 blocker (must NOT be started before α blockade)

·          Heart failure: as usual, after α-blockade

·          T2DM: as usual

 

Intra-op issues:

Hypertension

Prevention:

·          Avoid handling + communication

·          Avoid indirect SNS (ephedrine, metaraminol)

·          Avoid histamine (atracurium, sux, morphine)

·          Mg2+ 4g in 20 mins, 1g/h

Treatment:

·          Phentolamine 0.5mg/mL – use like metaraminol

·          Esmolol 0.5mg/kg + 50mcg/kg/min

·          Labetalol 5mg/mL

·          GTN 10-200mcg/min

Hypotension

·          Caused by clamping of adrenal vein / removal of tumour

·          Prevention: stop a-blocker 1-2 days pre-op

·          Treatment: noradrenaline, vasopressin, ICU post-op

 

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