Interesting Case involving a pheo - how would you approach?

[Laurel123]

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This is a 50 year old woman who about 5 years ago presented with paroxysmal hypertension and diaphoresis and positive metanephrines in the urine. She was found to have an adrenal mass, which she had removed.

Interestingly, the pathology was found to be adenoma with no sign of pheo. Since the surgery, her metanephrines stayed high, but she has not had any symptoms. She has had a million dollar workup to look for the hidden pheo, but it has never been found.

Her endocrinologist has put her on beta blockers and prednisone, but no alpha blockers. I don't really know why. But she has had no symptoms since the adrenalectomy and has even had an elbow surgery and some general anesthetic for a superficial thing since then. She was not alpha blocked for those surgeries and did fine.

She is also obese and one of those fibromyalgia types on chronic dilaudid. Airway is fine.

She will be coming to me for a shoulder surgery.

How would you guys approach this? My first thought was to just do a general and have some antihypertensives ready... But some people have been suggesting A-lines and CVP's, which seems like overkill, though honestly I haven't taken care of a pheo patient before.

 

[Jeff05]

she probably has an extra-adrenal pheo (10%). just because they haven't found it, doesn't mean it's not there.

CVP - useless.
a line - you need an a line, in this case, if you expect BP lability. since the surgical site is not near the pheo (unless the pheo is in the shoulder capsule), you don't need an a line.

plan - interscalene block after midaz/fent +/- LMA/tube.

 

[urge]

pent, sux, tube.


Why are you complicating your life?

 

[Gas]

It is probably an extra-adrenal pheo. I would get that taken care of before shoulder surgery, but if for whatever reason she does not, then pre-induction A-line, GA, good hydration, have anti-hypertensives ready, and because they are not directly manipulating the tumor I would not expect too much BP lability outside of induction.

A-line is there for the assumption that she will drop quickly with induction. She has not been alpha-blocked, so in my mind she is chronically vasoconstricted and volume depleted. She could tank with vasodilation. If you cancel the case, get her to see a real endocrinologist who will give her an alpha blocker, and if her diaphoresis/paroxysmal HTN abate (which I think they have according to your post saying she has no symptoms anymore), then you can probably get by without an A-line. In essence, your decision for an A-line should be based on the patient's history, physical, and any signs/symptoms of volume depletion. This is what they want to hear on the oral boards.

ISB's are nice, but you end up doing a GA anyway. No reason not to do an ISB for post-op pain though. I would not do a CVP. You can assume she is volume-depleted and just monitor I/O with a Foley assuming she has a good heart.

 

[Laurel123]

pent, sux, tube.


Why are you complicating your life?

That was my initial plan. Induce, tube, fix shoulder and wakeup. Make sure my cart is well stocked with the usual antihypertensives.

From what I gather, this woman pretty much spends half her life at the hospital and the clinic and has travelled around the country seeing countless specialists for years. She is hypersensitive to any change in her symptoms and despite her positive metanephrines and inability of the specialists to find the extraadrenal pheo - she hasn't had any symptoms for a few years.

 

[VentdependenT]

Do the case if her BP's/HR and symptoms are controlled and there is no plan for further work-up on her condition per her endocrinologist. I don't know why the hell they cant find the damn thing with a MIBG. Whatever. If there is no recent pre-op note in the chart demonstrating that, then you gotta get on the phone. Major pain in the tail, but you gotta do it.

As for the case itself, I don't think anyone would falt you for putting in an A-Line. I certainly wouldn't.

However, personally, I wouldn't.

She gets a ISB, a tube, and a bp-cuff.