Quick question re: pheo

[Idiopathic]

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So mid-70s female for resection of active pheo next day, needs to be signed off on. she is rx with alpha blockade to the point of orthostasis, looks appropriately teed up.

of note, she has history of TIA and CVA with mild residual symptoms, and incidental 60-80% LICA stenosis in 2008 that was noted at outside hospital and never followed up on.

do you postpone the pheo to get the carotid worked up? if the stenosis is the same/worse, do you do the carotid first? would you do both cases at the same time?

 

[lushmd]

do you postpone the pheo to get the carotid worked up? if the stenosis is the same/worse, do you do the carotid first? would you do both cases at the same time?

No, no, and no. I would proceed with pheo rsxn assuming that she has significant carotid stenosis and aim to maintain a reasonable MAP based on her baseline MAP (at least 80 mm Hg). I don't think that CEA prior to or just after pheo resection is a good plan. As you know, CEAs involve significant hemodynamic fluctuations that would only be exacerbated by concomitant pheo. Deal with the pheo first and then bring her back later for CEA later if indicated. Given that it wouldn't affect my anesthetic plan, I wouldn't repeat carotid dopplers pre-op.

 

[Depakote]

No, no, and no. I would proceed with pheo rsxn assuming that she has significant carotid stenosis and aim to maintain a reasonable MAP based on her baseline MAP (at least 80 mm Hg). I don't think that CEA prior to or just after pheo resection is a good plan. As you know, CEAs involve significant hemodynamic fluctuations that would only be exacerbated by concomitant pheo. Deal with the pheo first and then bring her back later for CEA later if indicated. Given that it wouldn't affect my anesthetic plan, I wouldn't repeat carotid dopplers pre-op.

If she's significantly alpha-blocked, what would you use to keep her MAP up?

 

[lushmd]

Well, this likely won't be a significant issue until after adrenal vein ligation. Until then, it would likely be more a matter of titrating anti-hypertensive medications than instituting pressor therapy. Following adrenal vein clipping, MAP can be maintained by volume expansion and pressor use (phenylephrine, norepinephrine, etc...). In my admittedly limited experience, these pts will still respond to catecholamine infusions despite adequate preop alpha blockade. If its really an issue, add vasopressin (which acts through distinct receptors).

 

[proman]

I would fix the pheo first. Was her stroke in the consistent with left carotid insufficiency? I'd also use NIRS in this setting, getting a baseline awake on room air and awake on oxygen. My goal would be to keep her cerebral oximetry at baseline, and also her MAP at her awake baseline.

I don't know why the endocrinologists haven't been more aggressive with adding beta blockade. I've found that relying solely on alpha blockade to be disappointing. I like nitroprusside for the downer and norepi for the upper. Like Lushmd said, they'll still respond to catecholamines.

 

[Depakote]

Well, this likely won't be a significant issue until after adrenal vein ligation. Until then, it would likely be more a matter of titrating anti-hypertensive medications than instituting pressor therapy. Following adrenal vein clipping, MAP can be maintained by volume expansion and pressor use (phenylephrine, norepinephrine, etc...). In my admittedly limited experience, these pts will still respond to catecholamine infusions despite adequate preop alpha blockade. If its really an issue, add vasopressin (which acts through distinct receptors).

cool, thanks!

 

[Idiopathic]

i was mainly concerned with the spectre of severe hypotension, even transient, as provocation for cerebral ischemia. pheo patients have a pretty high risk of periop hypotension and it isnt always immediately correctable. So, my concern is that this patient may not tolerate even a brief period of time with a MAP in the 30-40 range.

Whats the risk of studying/intervening on the carotid with a stent and then moving on to the pheo? she would be delayed, admittedly, but does anyone think its worth exploring?

 

[sevoflurane]

TIA/CVA 2/2 to stenotic LICA seems to be a pretty good reason to get a CEA anyways. Adrenal surgery will likely have swings in B.P.

Get vascular consult and have the surgeons weigh in on the decision.

That being said, if you have gtt's on board at the push of a button, you should be able to easily control b.p. post op. Norepi is hard to ignore even in the presence of phenoxybenzamine and atenolol.

The question is which one comes first. CEA is intermediate surgery. Pheo is a more risky surgery than CEA. I would argue brain protection takes precedence and therefore CEA first if it needs to be done anyways (symptoms and 60-80% stenosis).

She needs to have symptoms controlled before CEA (alpha/beta blockade).

Really though, I feel this is a bit of a grey area. It could be argued both ways.

 

[Idiopathic]

yeah i delayed her surgery until we could eval her carotids more throughly (at least a recent doppler) and then i figure id let the operative team determine the best course. if it were up to me, id want the carotid either intervened upon or judged unintervenable because i feel like she would have a double digit stroke risk with a symptomatic carotid lesion after pheo.

i agree you could keep her pressure up but at some point you will almost definitely be hypotensive and i have no idea how much hypotension is too much in this patient, as opposed to the patient who can tolerate a brief period.

 

[sevoflurane]

yeah i delayed her surgery until we could eval her carotids more throughly (at least a recent doppler) and then i figure id let the operative team determine the best course. if it were up to me, id want the carotid either intervened upon or judged unintervenable because i feel like she would have a double digit stroke risk with a symptomatic carotid lesion after pheo.

i agree you could keep her pressure up but at some point you will almost definitely be hypotensive and i have no idea how much hypotension is too much in this patient, as opposed to the patient who can tolerate a brief period.

You are right, can't keep a norepi gtt going forever.

FWIW, I woulda done the same Idio 👍

 

[proman]

I think the risk/benefit ratio goes the other way:

The risk of cerebral injury during or after pheo resection is likely lower than the risk of hypertensive pheo emergency during CEA for moderate stenosis.

This is such a rare combination you won't have hardly any evidence to guide you. What's the operation (lap vs open?), where is the pheo (adrenal or elsewhere), what is the distribution of the neuro injury (left carotid or somewhere else?), was the TIA really focal or could it have been a pheo-driven hypertensive event (like lacunar infarct or bleed?). There is evidence that cerebral angiopathy improves after alpha blockade and resection (PubID 11810017). There's also a case report of an unknown pheo causing death post CEA from hypertensive emergency (PubID 7698969).

I'd proceed with the case, although I don't think you could be faulted for delaying. Preinduction arterial line, central line, cerebral oximeter as described above, pressors in line and ready to be bolused. It's very predictable when the hypotension will be. And this should be your only room.

 

[Idiopathic]

doesnt matter, shes adequately alpha blocked and to me, the pheo is a non factor for a carotid stent, which is what i would want in this case. if it had to be a big CEA then id consider doing it under regional.

the only thing i would actually be worried about is refractory hypotension in the immediate operative/perioperative period and how she would be affected by 1-10 minutes of MAP 30-40. im not worried at all about a hypertensive crisis during a CEA...I feel like thats easier to control acutely and less likely to cause irreversible damage.

thoughts?

 

[aredoubleyou]

Given that her LICA was dx as stenosed in 2008, I would have ASSUMED that the carotids were looked at around that time - pretty run o the mill carotid w/u. If they were and she has no new sx, than proceed. Otherwise I dont think you did the wrong thing. Theres no need being a hero and not knowing if you have a tight carotid, cause the surgeon wont be on your side in court.

 

[proman]

doesnt matter, shes adequately alpha blocked and to me, the pheo is a non factor for a carotid stent, which is what i would want in this case. if it had to be a big CEA then id consider doing it under regional.

I'm assuming you don't think her neuro event doesn't matter. It should because in all likelihood it was the pheo and not the carotid that caused it. A pheo is a contraindication to any routine operation no matter how well blocked. Pheos get blocked so they can come out. I don't see how doing a CEA under regional is any safer vs GA. A carotid stent can be extremely hemodynamically labile, particularly when they deploy the stent. I don't see this as a safe option. Pheos are time bombs waiting to go off, it has to come out before anything else. BTW, ionic contrast has been shown to provoke catecholamine release from pheos (non-ionic is much less but the risk is still there).

the only thing i would actually be worried about is refractory hypotension in the immediate operative/perioperative period and how she would be affected by 1-10 minutes of MAP 30-40. im not worried at all about a hypertensive crisis during a CEA...I feel like thats easier to control acutely and less likely to cause irreversible damage.

thoughts?

The only thing? It seems a little narrow-focused to be concentrating on the risk of hypotension (which we are the experts of treating) as this patients biggest problem. Good coordination with the surgeon before the pheo gets isolated should limit the degree and spent hypotensive. I've asked several people, including a vascular surgeon I trust. They all concur the pheo gets done first.

A couple of days have gone by, what's happened?

 

[Idiopathic]

I'm assuming you don't think her neuro event doesn't matter. It should because in all likelihood it was the pheo and not the carotid that caused it. A pheo is a contraindication to any routine operation no matter how well blocked. Pheos get blocked so they can come out. I don't see how doing a CEA under regional is any safer vs GA. A carotid stent can be extremely hemodynamically labile, particularly when they deploy the stent. I don't see this as a safe option. Pheos are time bombs waiting to go off, it has to come out before anything else. BTW, ionic contrast has been shown to provoke catecholamine release from pheos (non-ionic is much less but the risk is still there).



The only thing? It seems a little narrow-focused to be concentrating on the risk of hypotension (which we are the experts of treating) as this patients biggest problem. Good coordination with the surgeon before the pheo gets isolated should limit the degree and spent hypotensive. I've asked several people, including a vascular surgeon I trust. They all concur the pheo gets done first.

A couple of days have gone by, what's happened?

i dont mean it to be narrow minded, but the hypotension that might be tolerated in another patient would probably not be tolerated in this one, so it is my most pressing UNIQUE concern (clearly pheos and carotids are complicated cases on their own merits). ill let you know when i hear the results of the carotid studies and the plans.