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LETTER TO THE EDITOR

Catastrophic Hemodynamic Changes in a Patient with Undiagnosed Pheochromocytoma Undergoing Abdominal Hysterectomy

Department of Anesthesiology, American University of Beirut, Beirut, Lebanon, abaraka{at}aub.edu.lb

To the Editor:

Tarant et al. (1) reported a patient with acute appendicitis whose surgery was cancelled because of the suspicion of undiagnosed pheochromocytoma. In patients with undiagnosed pheochromocytoma, incidental surgery is often lethal (2). The present case report illustrates this tragic outcome in a female patient with undiagnosed pheochromocytoma who underwent abdominal hysterectomy.

A 45-yr-old female was scheduled for total abdominal hysterectomy. Her preoperative arterial blood pressure was 150/80 mm Hg and her heart rate was 105 bpm. General anesthesia was induced with lidocaine 1.5 mg · kg^–1, propofol 2 mg · kg^–1, fentanyl 2 µg · kg^–1, and rocuronium 0.6 mg · kg^–1. After induction of anesthesia, her arterial blood pressure abruptly increased up to 180/100 mm Hg and her heart rate increased to 130 bpm. The trachea was intubated, and anesthesia was maintained with sevoflurane in a mixture of nitrous oxide and oxygen (2:1). During surgery, her arterial blood pressure fluctuated between 120/80 and 150/90 mm Hg. At the end of surgery, sevoflurane was discontinued and neuromuscular blockade was reversed with neostigmine 2.5 mg and glycopyrrolate 0.5 mg. After discontinuation of the anesthesia and reversal of neuromuscular blockade, her systolic blood pressure increased to 160 mm Hg and her heart rate increased to 160 bpm. IV incremental doses of propranolol up to a total dose of 2 mg were followed by severe bradycardia and pulmonary edema. Transesophageal echocardiography showed severe global hypokinesia which progressed into akinesia and asystole. Cardiopulmonary resuscitation was continued for 30 min with no success. Autopsy revealed a 5 cm right adrenal pheochromocytoma.

Unexplained severe hypertension and tachycardia after induction of general anesthesia must raise the suspicion of undiagnosed pheochromocytoma. This report supports the recommendations of Tarant et al. (1): whenever undiagnosed pheochromocytoma is suspected, incident surgery must be cancelled, since surgery in the presence of undiagnosed pheochromocytoma is often lethal (2), with a mortality rate close to 80% (3).

REFERENCES

1. Tarant NS, Dacanay RG, Mecklenburg BW, et al. Acute appendicitis in a patient with undiagnosed pheochromocytoma. Anesth Analg 2006;102:642–3.[Abstract/Free Full Text]
2. Sellerold OFM, Raeder J, Sensetch R. Undiagnosed pheochromocytoma in the perioperative period. Acta Anaesthesiol Scand 1985;29:474–9.[Web of Science][Medline]
3. O’Riordan JA. Pheochromocytoma and anesthesia. Int Anesthesiol Clinic 1997;35:99–127.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Dabbous, A. Articles by Baraka, A. Search for Related Content PubMed PubMed Citation Articles by Dabbous, A. Articles by Baraka, A.