Interesting Case

[ThinkFast007]

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MSIV here:

I ran into an attending the other day who I worked with briefly on this case (ok fine, I didnt do much except start IVs, hang IVFs, and observe). Given the 'stressors' of that particular day when the attending and I were on this case, we bonded. Anyways, this was the case. How would you approach it?


24 yo lady who has never had any complcations in her previous NSVDs who denies a past h/o of any medical illness comes in. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 190/100 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 4 cm x 5cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha- followed by beta-blockade with phenoxybenzamine and metoprolol.

I forget what the indication was, but the OB/GYN stated that C-Section was going to be necessary. How would you approach the case?

 

[militarymd]

Mg infusion...stabilizes pheo membranes and minimizes neurotransmitter release.


A-line for monitoring.

Central access for rapid administration of vasoactive drug as necessary.

Spinal.

 

[SilverStreak]

Mg infusion...stabilizes pheo membranes and minimizes neurotransmitter release.


A-line for monitoring.

Central access for rapid administration of vasoactive drug as necessary.

Spinal.

Don't they usually end up needing to have the mass removed? I vaguely remember something about a patient needing surgery to remove one of these using a nasal approach. Also seems like I remember something about there being a medical option for treatment.

How would the neurotransmitters be affected by anesthetics? I think this would be a really difficult case because not only would you be potentially fighting her physiology if you triggered a response by the drugs you're giving, but also could you predict how she would react to your treatments?

 

[Skrubz]

So it sounds like the case boils down to a 24 y/o pregnant multip with a pheo, currently on phenoxybenzamine and metoprolol, who needs to go for C/S. How many weeks is she? (i.e. is the baby going to survive s/p delivery)

Assuming she's well-controlled on phenoxybenzamine and metoprolol, I'd probably elect to do an epidural and slowly titrate in 2% lidocaine (with bicarb and epi), while monitoring her HR and BP. You mentioned that she had invasive monitoring placed in the ICU (and I'm assuming at least an art line and a central line). While placing the epidural, I'd try to avoid benzos given the depressant effects it can have on the newborn and try to do it just with ample doses of reassurance. I'd also have phentolamine and nitroprusside in line and ready to go.

Of course, this is from the perspective of a CA-1 who hasn't dealt with any pheos.

 

[ThinkFast007]

sorry guys, memory is kinda fading the exact details. From what I recall, she was b/w 30-32 WGA 🙁

 

[Skrubz]

Don't they usually end up needing to have the mass removed? I vaguely remember something about a patient needing surgery to remove one of these using a nasal approach. Also seems like I remember something about there being a medical option for treatment.

How would the neurotransmitters be affected by anesthetics? I think this would be a really difficult case because not only would you be potentially fighting her physiology if you triggered a response by the drugs you're giving, but also could you predict how she would react to your treatments?

I think you're thinking about pituitary tumors... which you can take out with a transpenoidal approach. And you can treat a prolactinoma with bromocriptine, IIRC.

A spinal (or epidural) provides a sympathetic block, which should theoretically prevent and sympathetic discharge from reaching the adrenal medulla (where the pheo sits). Or at least that's how it's supposed to work.
__________________
"Pickles!"
PGY-2/CA-1 (2005-6): Stanford University, Anesthesia
Skrubz is online now Edit/Delete Message

 

[SilverStreak]

I think you're thinking about pituitary tumors... which you can take out with a transpenoidal approach. And you can treat a prolactinoma with bromocriptine, IIRC.

A spinal (or epidural) provides a sympathetic block, which should theoretically prevent and sympathetic discharge from reaching the adrenal medulla (where the pheo sits). Or at least that's how I think it works.
__________________
"Pickles!"
PGY-2/CA-1 (2005-6): Stanford University, Anesthesia
Skrubz is online now Edit/Delete Message

You're right I was thinking about a pituitary tumor... 😀

 

[toughlife]

Don't they usually end up needing to have the mass removed? I vaguely remember something about a patient needing surgery to remove one of these using a nasal approach. Also seems like I remember something about there being a medical option for treatment.

How would the neurotransmitters be affected by anesthetics? I think this would be a really difficult case because not only would you be potentially fighting her physiology if you triggered a response by the drugs you're giving, but also could you predict how she would react to your treatments?

Boy! that'd would be some surgery (trying to resect and suprarenal tumor using a nasal approach). Sorry, I couldn't resist.

 

[Ruban]

Was there anything in the hx that made them suspect pheo over preeclampsia? I am wondering because if I saw a pregnant women with htn, the first thing that would be on my mind would be preeclampsia.

Moreover, where I did my OB rotation, they often used Labetalol as the first-line drug to lower BP in patients with preeclampsia. This would be disastrous in a patient with secondary HTN due to pheo.

 

[toughlife]

Was there anything in the hx that made them suspect pheo over preeclampsia? I am wondering because if I saw a pregnant women with htn, the first thing that would be on my mind would be preeclampsia.

Moreover, where I did my OB rotation, they often used Labetalol as the first-line drug to lower BP in patients with preeclampsia. This would be disastrous in a patient with secondary HTN due to pheo.

I ran into an attending the other day who I worked with briefly on this case (ok fine, I didnt do much except start IVs, hang IVFs, and observe). Given the 'stressors' of that particular day when the attending and I were on this case, we bonded. Anyways, this was the case. How would you approach it?


24 yo lady who has never had any complcations in her previous NSVDs who denies a past h/o of any medical illness comes in. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 190/100 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 4 cm x 5cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha- followed by beta-blockade with phenoxybenzamine and metoprolol.

I forget what the indication was, but the OB/GYN stated that C-Section was going to be necessary. How would you approach the case?

I assume urine + for VMA and elevated blood catecholamines coupled with radiologic evidence should suffice for pheo dx. I would also expect a hx of symptoms rather than acute onset. Goes without a saying that since pt is gestational, you'd want to check for proteinuria, and do PE to chk for edema to r/o pre-eclampsia.

 

[ThinkFast007]

I ran into an attending the other day who I worked with briefly on this case (ok fine, I didnt do much except start IVs, hang IVFs, and observe). Given the 'stressors' of that particular day when the attending and I were on this case, we bonded. Anyways, this was the case. How would you approach it?


24 yo lady who has never had any complcations in her previous NSVDs who denies a past h/o of any medical illness comes in. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 190/100 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 4 cm x 5cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha- followed by beta-blockade with phenoxybenzamine and metoprolol.

I forget what the indication was, but the OB/GYN stated that C-Section was going to be necessary. How would you approach the case?

I assume urine + for VMA and elevated blood catecholamines coupled with radiologic evidence should suffice for pheo dx. I would also expect a hx of symptoms rather than acute onset. Goes without a saying that since pt is gestational, you'd want to check for proteinuria, and do PE to chk for edema to r/o pre-eclampsia.

yup...thought i included it. yah we did an MRI she had the adr mass.

yes, she did have the s/s of pheo...i know for sure she felt palps and was sweating a lot.

 

[SilverStreak]

Boy. that'd would be some surgery (trying to resect and suprarenal tumor using a nasal approach). Sorry, I couldn't resist.

Hahaha...I can laugh at myself when I'm a goober

 

[toughlife]

yup...thought i included it. yah we did an MRI she had the adr mass.

yes, she did have the s/s of pheo...i know for sure she felt palps and was sweating a lot.

Heard of that along with wild fluctuations in BP.

 

[Ruban]

Hi Toughlife,
I noted the part about the high VMA, but IIRC, when we worked up pts with HTN during pregnancy, we didn't routinely order urine metanephrines. Should that be standard of care?

Also, I've read that a large # of pts with pheo don't have the classic SSx. So if the pt lacked SSx, and you were the doc, would you have ordered urinary metanephrines? I guess I'm just concerned about missing the diagnosis if it comes up in the future.

I ran into an attending the other day who I worked with briefly on this case (ok fine, I didnt do much except start IVs, hang IVFs, and observe). Given the 'stressors' of that particular day when the attending and I were on this case, we bonded. Anyways, this was the case. How would you approach it?


24 yo lady who has never had any complcations in her previous NSVDs who denies a past h/o of any medical illness comes in. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 190/100 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 4 cm x 5cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha- followed by beta-blockade with phenoxybenzamine and metoprolol.

I forget what the indication was, but the OB/GYN stated that C-Section was going to be necessary. How would you approach the case?

I assume urine + for VMA and elevated blood catecholamines coupled with radiologic evidence should suffice for pheo dx. I would also expect a hx of symptoms rather than acute onset. Goes without a saying that since pt is gestational, you'd want to check for proteinuria, and do PE to chk for edema to r/o pre-eclampsia.

 

[toughlife]

Hi Toughlife,
I noted the part about the high VMA, but IIRC, when we worked up pts with HTN during pregnancy, we didn't routinely order urine metanephrines. Should that be standard of care?

Also, I've read that a large # of pts with pheo don't have the classic SSx. So if the pt lacked SSx, and you were the doc, would you have ordered urinary metanephrines? I guess I'm just concerned about missing the diagnosis if it comes up in the future.

I would not order urine metanephrines right off the bat. You want to work-up for pre-eclamp, since it's the most common cause of htn in pregnancy. For this you need to know gestational age (<20wk vs >20wks), is it their first pregnancy, ethnicity (more common in blacks), timing of sx, etc.

I'd proceed down the pheo path depending on symptoms, presentation, and after r/o pre-eclamp. You gotta be thinking like a doc so you'd be thinking chronic htn, pheo, coarctation of the aorta, hyperaldosteronism, renal artery stenosis, etc, etc. You likely won't work them up for everything but you gotta have those possibilities in the back of your head.

You know medicine is not black & white. A lot of judgment is required to dx a patient and this can only be done with the proper education and training. No way around that as others would have you believe.

I'm only a fourth year so take everything I say with a grain of salt.

 

[cubs3canes]

I'm only a fourth year so take everything I say with a grain of salt.

The question is why are you still working? It is 3:15 and I am already into my daily buzz of daquiris and margaritas.

 

[toughlife]

The question is why are you still working? It is 3:15 and I am already into my daily buzz of daquiris and margaritas.

nice! I gotta get going with my Cuba libres and XX (dos equis) cervezas.

 

[Noyac]

If this is truely a pheo. I would not be too excited about doing the c/s at 30-32 weeks. I would like to see her medically managed for a few more weeks (alpha and beta blockers can control the pheo) to give the fetus a fighting chance. If things were not going well then proceed to c/s.

For the case (IF Iwere to agree to do it), spinal would be nice but remember that even the sympathectomy can be overcome by the pheo's release since the sympath is only to the level of the spinal (T10-4). Doing the c/s could very easily disrupt the pheo and you could be in a hypertensive crisis in no time. A-line and central line are mandatory. I would really consider GETA. Now if yo are going to do the c/s why not remove the pheo while your in there.

Great Great case

 

[Idiopathic]

If this is truely a pheo. I would not be too excited about doing the c/s at 30-32 weeks. I would like to see her medically managed for a few more weeks (alpha and beta blockers can control the pheo) to give the fetus a fighting chance. If things were not going well then proceed to c/s.

For the case (IF Iwere to agree to do it), spinal would be nice but remember that even the sympathectomy can be overcome by the pheo's release since the sympath is only to the level of the spinal (T10-4). Doing the c/s could very easily disrupt the pheo and you could be in a hypertensive crisis in no time. A-line and central line are mandatory. I would really consider GETA. Now if yo are going to do the c/s why not remove the pheo while your in there.

Great Great case

I agree with your management (Im sure you are relieved 😉 )

What I dont like about this case is the delay between sy/sx and dx. If you have ever tried to dx a pheo, it isnt quick (unless you go right to CT). 24-hour labs, etc. and during this time, what are you doing for the pressure? And I GUARANTEE that a preeclamptic workup was done first, which kills more time.

So...Ive seen patients managed longer for less on inpatient bedrest and anti-HTN meds. I agree that this woman can go to 36 weeks (at least), get her sympathetics calmed down, and do a GETA. As for doing the surgeries consecutively, I dont know about that. I think with rapid fluid shifts, etc. that occur after delivery, one should wait 3-5 days.

 

[VentdependenT]

Speaking of Pheo's, I did my first one today, laproscopic. 65 yr old female with hx of R sided ischemic CVA found to have pheo during a hyptertensive emergency last month. Suffered a STEMI with low bump in trops. Cath showed fairly clean coronaries and some RWMA from stunned myocardium. EF 50%.

Case went fine. Tanked the hell out of her, 7 liters of crystalloid in a 55kg, only 300ml blood loss. Threw in the a-line, TLC-IJ, and an echo. Kept it in deep transgastric view. Helped with the volume status as well.

I gotta say that Nicardipine was the biznomb for the case. Flipped it on when I found myself bolusing NTG and Esmolol. Flipped it off when vein was ligated. No pressors post removal. As Borat would say, "very nice."

I was a bit suprised how much volume this lady took. She had been on phenoxybenzamine for a couple of weeks. I'd think her intravascular space would have equilibrated. Bah. Her bp pre-op was 80/40. Hehehe.

 

[epidural man]

would anybody use precedex for a pheo case?

It seems like a perfect adjunct to your anesthetic in a pheo case.