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ANESTHETIC MANAGEMENT OF A PARTURIENT WITH PHEOCHROMOCYTOMA--A CASE REPORT
Abstract Number: SA-50
Abstract Type: Case Report/Case Series
INTRODUCTION: Pheochromocytoma is a catecholamine-secreting tumor known to precipitate life-threatening hypertension. The occurrence of this condition is exceedingly rare in the parturient, presenting a challenge for anesthetic management.
CASE: A 36 year-old G7P4 at 19 weeks gestation presented with hypertensive urgency. Her medical history is notable for Von Hipple-Lindau Syndrome, pheochromocytoma status-post remote bilateral adrenalectomy with subsequent primary adrenal insufficiency, recurrence of norepinephrine-secreting paraganglioma, asthma, DVT on heparin, and complex social situation. After weeks of poor outpatient compliance, she was admitted at 24 weeks for medical management for the duration of her pregnancy.
A pharmacologic regimen consisting of doxazosin and labetalol was initiated. A hydromorphone PCA was also required for tumor-related abdominal pain, which precipitated hypertensive episodes. A PICC was placed for prolonged access. In consultation with vascular and oncologic surgery, the decision was made to forgo resection of the pheochromocytoma given its proximity to the IVC and the need for bypass during the operation.
After a multidisciplinary team discussion, an elective cesarean delivery was planned at 33.2 weeks gestation. Given her relative hemodynamic stability with maintenance of alpha and beta blockade, we utilized a combined spinal-epidural technique as the primary anesthetic.
Preoperatively, additional intravenous and arterial access was obtained. Several vasoactive infusions were available to counteract hyper- or hypotension as needed. Intraoperatively, midazolam was administered for anxiolysis, and a CSE was placed. After an intrathecal dose of bupivacaine 2.5mg and fentanyl 15mcg, we slowly titrated 2% lidocaine via the epidural catheter to achieve a surgical anesthetic level. During the operation, our patient required use of a nicardipine infusion for hypertension but was overall hemodynamically stable.
Postoperatively, in addition to her hydromorphone PCA, the epidural catheter was maintained for analgesia using an infusion of bupivacaine, fentanyl, and clonidine. She was given intermittent boluses of IV labetalol and nicardipine for further blood pressure stabilization, which she no longer required after optimization of pain control and re-initiation of her oral anti-hypertensives. She was admitted to the ICU for postoperative monitoring.
DISCUSSION: There is no consensus recommendation for the anesthetic management of patients with pheochromocytoma, particularly the parturient. As such, anesthetic decisions should be tailored to the individual. Our primary management concerns included the choice of anesthetic technique and maintenance of hemodynamic stability. Therefore, a wide range of vasoactive medications, adequate access, and additional help should be readily available. Making thorough preparations with a multidisciplinary team approach is also essential for caring for these high-risk patients.