Summary
Recent advances in pharmacology, physiology, and biochemistry have revealed the pathophysiologic derangements encountered in pheochromocytoma, and the rational foundations for its management; this is illustrated in reports of two cases.
For pre-operative preparation we use phenoxybenzamine to block the alpha adrenergic receptors, as it allows improvement in the cardiovascular status, expansion of the blood volume, decrease in the basal metabolic rate and plasma free fatty acids and protection against adrenergic crisis. We use propranolol pre-operatively subsequent to effective alpha adrenergic receptor blockade only to control serious dysrhythmia, angina or myocardial ischaemia. The alpha and beta blocking agents are withheld 12 hours prior to operation.
Preanaesthesic medication includes morphine, diazepam and scopolamine and induction and subsequent maintenance of anaesthesia are achieved with diazepam, fentanyl, pancuronium, nitrous oxide and oxygen. Lidocaine (50-100 mg) is administered prophylactically before induction of anaesthesia, tracheal intubation and concomitant with exaggerated pressor responses to surgical manipulations. These latter reactions are managed by phentolamine ( 1-5 mg ) until the first manifestation of tachyphylaxis; at this juncture we resort to a drip of sodium nitroprusside ( 50-100 ζ/minute).
Successful management of pheochromocytoma demands anticipation of potential problems, prior preparation of necessary medication, adequate monitoring and close post-operative observation.
Résumé
Les acquisitions récentes dans le domaine de la pharmacologie, de la physiologie et de la biochimie ont permis une meilleure compréhension de la physiopathologie du phéochromocytome, et une conduite thérapeutique plus rationnelle. Nous présentons nos cas à titre ďillustration.
Nous utilisons la phenoxybenzamine en préparation à ľintervention. Le blocage α ainsi produit améliore ľétat cardiovasculaire, permet la réexpansion du volume sanguin, amène une diminution du métabolisme basai et des acides gras plasmatiques libres, en plus de protéger contre la crise adrénergique. En pré-opératoire, le propranolol n’est utilisé qu’après obtention ďun blocage α efficace, pour le contrôle ďarythmies graves, ďangine ou ďischémie myocardique. Les bloqueurs α et β sont cessés 12 heures avant la chirurgie.
Nos opérés ont reçu du diazepam, de la morphine et de la scopolamine en prémédication. Pour ľinduction et le maintien de ľanesthésie, nous avons utilisé le diazepam, le fentanyl, le pancuronium, le protoxyde ďazote et ľoxygène. La lidocaïne en doses de 50 à 100 mg a été administrée de façon préventive avant ľintubation trachéale, et aussi lors des poussées hypertensives secondaires aux manipulations. Ces poussées hypertensives ont été contrôlées à ľaide de Régitine (1-5 mg) jusqu’à ce que survienne la tachyphylaxie, alors que nous avons passé au nitroprussiate ( 50-100 ζ/min ).
Ľapproche ďun phéochromocytome nécessite ľanticipation des problèmes potentiels, la préparation à ľavance des médicaments qui peuvent devenir nécessaires subitement, un monitoring adéquat et une surveillance attentive en post-opératoire.
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El-Naggar, M., Suerte, E. & Rosenthal, E. Sodium nitroprusside and lidocaine in the anaesthetic management of pheochromocytoma. Canad. Anaesth. Soc. J. 24, 353–360 (1977). https://doi.org/10.1007/BF03005108
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DOI: https://doi.org/10.1007/BF03005108