Anaesthesia, 1976, Volume 31, pages 60-62 CASE R E P O R T
Effects of sodium nitroprusside during the excision of phaeochromocytoma
J. C. C S A N K Y - T R E E L S , W . P. L A W I C K V A N PABST, J . W. J . B R A N D S A N D L. S T A M E N K O V I C
Phaeochromocytoma is a tumour of the adrenal medullary cells of chromaffin origin, which, although histologically benign, may be dangerous because of excessive secretion of adrenaline and noradrenaline. The growth may not be confined to the adrenals but may occur wherever chromaffin tissue is found, for example along the sympathetic chain, the para-aortic areas, the aortic bifurcation, the retroperitoneum and even in the bladder. Clinical features, resulting from the release of catecholamines, include hypertension, paroxysmal or continuous, hyperhydrosis, hyperglycaemia, increased oxygen consumption, haemoglobin percentage and haematocrit reading, and an elevated basal metabolic rate. The diagnosis is confirmed by measurement of single 24-hour urinary catecholamine or 3-methoxy, 4-hydroxymandelic acid (VMA) values, by certain radiological techniques, and by the effect of certain pharmacological agents, for example histamine to release stored catecholamines and to raise the blood pressure or phentolamine to lower it. Case report
The patient, a 32-year-old male weighing 79.5 kg, gave a history of low back pain for 2 years and of attacks of sudden uncontrollable aggressive behaviour during the past 18 months with periodic blurred vision. The family history showed that his father, grandfather and great-grandfather had suffered from similar attacks of aggressive behaviour, and a sister had undergone removal of a phaeochromocytoma. Clinical examination revealed a blood pressure of 215/130 mmHg, and a lumbar disc herniation was found at L4-5 level. The attacks of aggressive behaviour were not controlled by drug therapy. Intravenous pyelography showed no abnormality, but on arteriography a large tumour was demonstrated in the right suprarenal area. J. C. Cshnky-Treels, MD, W. P. Lawick van Pabst, MD, J. W. J. Brands, MD, Anaesthetists, Department of Anaesthesiology, Westeinde Hospital, The Hague, and L. Stamenkovic, MD, Anaesthetist, Department of Anaesthesiology, University of Leiden, Holland.
60
Effects of sodium nitroprusside during excision of phaeochromocytoma
61
Total VMA and metanefrine levels in a 24-hour urine specimen were 270 and 1.4 mg respectively. A phentolamine test was positive. Serum electrolytes were within the normal range. Preparation. The patient was admitted to hospital for operative removal of phaeochromocytoma. Pre-operative treatment included propranolol40 mg 4 times a day for 4 days and dibenzyline given in an intravenous drip, 1 mg per kg in 200 ml 5% glucose; the rate being adjusted to keep blood pressure between 150/90 and 130/90 mmHg. This medication was discontinued on the evening prior to operation. Anaesthesia. On the day of operation droperidol 5 mg and fentanyl 0.1 mg were given intramuscularly as premedication. Forty-five minutes later anaesthesia was induced using droperidol25 mg and fentanylO.8 mg intravenously; this was immediately followed by pancuronium 6.4 mg and orotracheal intubation. Anaesthesia was continued by nitrous oxide and oxygen in a ratio of 5:3 and intermittent positive pressure ventilation. Supplementary doses of pancuronium and fentanyl were given every half hour. Care was taken to avoid hypoxia and hypercarbia at all times. Monitoring during anaesthesia included the electrocardiogram, venous pressure by central line and arterial pressure by cannulation of the left radial artery. Blood pressure had been 250/100 mmHg immediately prior to induction and an intravenous infusion was started using sodium nitroprusside 100 mg in 500 ml 5% glucose, the rate being two drops per minute using an IVAC 501 infusion pump. Propranolol, lignocaine and phentolamine were not required. The nitroprusside infusion was discontinued and blood transfusion started just before clamping of the adrenal vein. Arterial pressure fell temporarily to 70 mmHg systolic on removal of the tumour, but rose almost immediately to 190/100 mmHg and the nitroprusside infusion had to be re-started at a rate of three drops per minute. This gave rise to suspicion that further catecholamine-secreting tumour was present. None was found on careful exploration of the right side and it became necessary to explore the left side through a separate incision. A smaller tumour was found on the left side, but following its removal arterial pressure remained high. Further search revealed two further tumours and it was only after all four tumours had been removed that blood pressure stabilised at 130/90 mmHg without nitroprusside infusion. Parallel changes were observed in blood sugar levels which rose from 70 to 270 mg% (4.0 to 15.2 mmol/l) during manipulations of tumour tissue. Histology confirmed the diagnosis of multiple phaeochromocytomata in the left adrenal and a large phaeochromocytoma with an adjacent adenoma consisting of phaeochromocytes in the right adrenal. There was a nodule of hyperplastic adrenal medulla tissue on the left side of the coeliac plexus. The patient made a good recovery though he requires cortisone replacement therapy. His behaviour is said to have improved.
Discussion The authors have found that the anaesthetic technique used in this case has given good results in the surgery of phaeochromocytoma. Atropine has been avoided because of its possible adrenergic effects and suxamethonium since ventricular dysrhythmias have been reported in association with these turnours.'
62
J. C . Csrinky-Treelset al.
Neurolept agents have been used without complications and it is considered that pancuronium is the relaxant of choice because of its vascular effects.2 Sodium nitroprusside, administered by intravenous infusion, has already been shown to be a safe and satisfactory agent for controlled hypotension during surgical operation^.^ Its action is immediate, by a direct effect on the vessel wall, and recovery occurs in 1 or 2 minutes. It is particularly applicable during removal of phaeochromocytoma. Blood pressure can be kept within normal limits during exploration and manipulation but, once the tumour has been removed, the nitroprusside can be discontinued with return to normal levels. This case illustrates the delicate control which can be achieved. Failure of blood pressure to return to normal levels following removal of the first tumour and cessation of nitroprusside was virtually diagnostic that more catecholamine-secreting tumour was present. This sequence was repeated until four tumours in all were excised. Summary A case report is presented which illustrates the use of sodium nitroprusside to control blood pressure levels during neurolept anaesthetic technique for removal of phaeochromocytoma. In this case the evanescent action of nitroprusside was advantageous since when the drug was discontinued elevation of blood pressure gave rise to suspicion that further catecholamine-secreting tumour was present. In all, four such tumours were removed from this patient.
Acknowledgments
The authors wish to thank Miss v.d. Watering and Miss Smeets for their technical assistance and the Department of Pharmacology of the University of Leiden for preparing the sodium nitroprusside solution. References 1. STONER,T.R.& URBACH,K.F. (1968) Cardiac arrhythmias associated with succinylcholine in a patient with pheochromocytoma. Anesthesiology, 29, 1228. 2. COLEMAN, A.J., DOWNING, J.W., LEARY,W.P., MOYES,D.S. & STYLES,M. (1972) The immediate cardiovasculareffects of pancuronium, alcuronium and tubocurarine in man. Anaesthesia, 27,415. 3. TAYLOR, T.H.,STYLES,M. & LAMMING, A.J. (1970) Sodium nitroprusside as a hypotensive agent in general anaesthesia. British Journal of Anaesthesia, 42, 859.
Effects of sodium nitroprusside during the excision of phaeochromocytoma
J. C. C S A N K Y - T R E E L S , W . P. L A W I C K V A N PABST, J . W. J . B R A N D S A N D L. S T A M E N K O V I C
Phaeochromocytoma is a tumour of the adrenal medullary cells of chromaffin origin, which, although histologically benign, may be dangerous because of excessive secretion of adrenaline and noradrenaline. The growth may not be confined to the adrenals but may occur wherever chromaffin tissue is found, for example along the sympathetic chain, the para-aortic areas, the aortic bifurcation, the retroperitoneum and even in the bladder. Clinical features, resulting from the release of catecholamines, include hypertension, paroxysmal or continuous, hyperhydrosis, hyperglycaemia, increased oxygen consumption, haemoglobin percentage and haematocrit reading, and an elevated basal metabolic rate. The diagnosis is confirmed by measurement of single 24-hour urinary catecholamine or 3-methoxy, 4-hydroxymandelic acid (VMA) values, by certain radiological techniques, and by the effect of certain pharmacological agents, for example histamine to release stored catecholamines and to raise the blood pressure or phentolamine to lower it. Case report
The patient, a 32-year-old male weighing 79.5 kg, gave a history of low back pain for 2 years and of attacks of sudden uncontrollable aggressive behaviour during the past 18 months with periodic blurred vision. The family history showed that his father, grandfather and great-grandfather had suffered from similar attacks of aggressive behaviour, and a sister had undergone removal of a phaeochromocytoma. Clinical examination revealed a blood pressure of 215/130 mmHg, and a lumbar disc herniation was found at L4-5 level. The attacks of aggressive behaviour were not controlled by drug therapy. Intravenous pyelography showed no abnormality, but on arteriography a large tumour was demonstrated in the right suprarenal area. J. C. Cshnky-Treels, MD, W. P. Lawick van Pabst, MD, J. W. J. Brands, MD, Anaesthetists, Department of Anaesthesiology, Westeinde Hospital, The Hague, and L. Stamenkovic, MD, Anaesthetist, Department of Anaesthesiology, University of Leiden, Holland.
60
Effects of sodium nitroprusside during excision of phaeochromocytoma
61
Total VMA and metanefrine levels in a 24-hour urine specimen were 270 and 1.4 mg respectively. A phentolamine test was positive. Serum electrolytes were within the normal range. Preparation. The patient was admitted to hospital for operative removal of phaeochromocytoma. Pre-operative treatment included propranolol40 mg 4 times a day for 4 days and dibenzyline given in an intravenous drip, 1 mg per kg in 200 ml 5% glucose; the rate being adjusted to keep blood pressure between 150/90 and 130/90 mmHg. This medication was discontinued on the evening prior to operation. Anaesthesia. On the day of operation droperidol 5 mg and fentanyl 0.1 mg were given intramuscularly as premedication. Forty-five minutes later anaesthesia was induced using droperidol25 mg and fentanylO.8 mg intravenously; this was immediately followed by pancuronium 6.4 mg and orotracheal intubation. Anaesthesia was continued by nitrous oxide and oxygen in a ratio of 5:3 and intermittent positive pressure ventilation. Supplementary doses of pancuronium and fentanyl were given every half hour. Care was taken to avoid hypoxia and hypercarbia at all times. Monitoring during anaesthesia included the electrocardiogram, venous pressure by central line and arterial pressure by cannulation of the left radial artery. Blood pressure had been 250/100 mmHg immediately prior to induction and an intravenous infusion was started using sodium nitroprusside 100 mg in 500 ml 5% glucose, the rate being two drops per minute using an IVAC 501 infusion pump. Propranolol, lignocaine and phentolamine were not required. The nitroprusside infusion was discontinued and blood transfusion started just before clamping of the adrenal vein. Arterial pressure fell temporarily to 70 mmHg systolic on removal of the tumour, but rose almost immediately to 190/100 mmHg and the nitroprusside infusion had to be re-started at a rate of three drops per minute. This gave rise to suspicion that further catecholamine-secreting tumour was present. None was found on careful exploration of the right side and it became necessary to explore the left side through a separate incision. A smaller tumour was found on the left side, but following its removal arterial pressure remained high. Further search revealed two further tumours and it was only after all four tumours had been removed that blood pressure stabilised at 130/90 mmHg without nitroprusside infusion. Parallel changes were observed in blood sugar levels which rose from 70 to 270 mg% (4.0 to 15.2 mmol/l) during manipulations of tumour tissue. Histology confirmed the diagnosis of multiple phaeochromocytomata in the left adrenal and a large phaeochromocytoma with an adjacent adenoma consisting of phaeochromocytes in the right adrenal. There was a nodule of hyperplastic adrenal medulla tissue on the left side of the coeliac plexus. The patient made a good recovery though he requires cortisone replacement therapy. His behaviour is said to have improved.
Discussion The authors have found that the anaesthetic technique used in this case has given good results in the surgery of phaeochromocytoma. Atropine has been avoided because of its possible adrenergic effects and suxamethonium since ventricular dysrhythmias have been reported in association with these turnours.'
62
J. C . Csrinky-Treelset al.
Neurolept agents have been used without complications and it is considered that pancuronium is the relaxant of choice because of its vascular effects.2 Sodium nitroprusside, administered by intravenous infusion, has already been shown to be a safe and satisfactory agent for controlled hypotension during surgical operation^.^ Its action is immediate, by a direct effect on the vessel wall, and recovery occurs in 1 or 2 minutes. It is particularly applicable during removal of phaeochromocytoma. Blood pressure can be kept within normal limits during exploration and manipulation but, once the tumour has been removed, the nitroprusside can be discontinued with return to normal levels. This case illustrates the delicate control which can be achieved. Failure of blood pressure to return to normal levels following removal of the first tumour and cessation of nitroprusside was virtually diagnostic that more catecholamine-secreting tumour was present. This sequence was repeated until four tumours in all were excised. Summary A case report is presented which illustrates the use of sodium nitroprusside to control blood pressure levels during neurolept anaesthetic technique for removal of phaeochromocytoma. In this case the evanescent action of nitroprusside was advantageous since when the drug was discontinued elevation of blood pressure gave rise to suspicion that further catecholamine-secreting tumour was present. In all, four such tumours were removed from this patient.
Acknowledgments
The authors wish to thank Miss v.d. Watering and Miss Smeets for their technical assistance and the Department of Pharmacology of the University of Leiden for preparing the sodium nitroprusside solution. References 1. STONER,T.R.& URBACH,K.F. (1968) Cardiac arrhythmias associated with succinylcholine in a patient with pheochromocytoma. Anesthesiology, 29, 1228. 2. COLEMAN, A.J., DOWNING, J.W., LEARY,W.P., MOYES,D.S. & STYLES,M. (1972) The immediate cardiovasculareffects of pancuronium, alcuronium and tubocurarine in man. Anaesthesia, 27,415. 3. TAYLOR, T.H.,STYLES,M. & LAMMING, A.J. (1970) Sodium nitroprusside as a hypotensive agent in general anaesthesia. British Journal of Anaesthesia, 42, 859.
