Desflurane and remifentanil use during resection of a cardiac pheochromocytoma

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.

Fast-Track Anaesthesia in Off-Pump Coronary Surgery: A Comparison of Normotensive and Hypertensive Patients

Objective

In this study, our aim was to investigate the efficacy and sufficiency of bispectral indeks (BIS) guided remifentanil-desflurane anaesthesia on intraoperative haemodynamic stability in both normotensive and hypertensive patients undergoing off-pump coronary artery bypass surgery.

Methods

Thirty adult, ASA I-III patients undergoing elective off-pump coronary surgery were included in the study. According to the presence of essential hypertension preoperatively, patients were divided into two groups. Haemodynamic parameters were recorded at 11 time points during the operation.

Results

There were no differences in the demographic data, heart rate and intraoperative and postoperative parameters between the groups. Arterial blood pressure and additional requirement of remifentanil were found to be significantly higher in the hypertensive group intraoperatively.

Conclusion

In patients undergoing off-pump coronary revascularisation surgery, intraoperative haemodynamic stabilisation with remifentanil-desflurane anaesthesia under BIS guidance was safely provided, but higher remifentanil doses were required in hypertensive patients.

Factors affecting the haemodynamic behaviour of patients undergoing pheochromocytoma and paraganglioma removal: A review

Pheochromocytoma and paraganglioma are catecholamine-secreting tumours associated with major haemodynamic upheavals. The cardiovascular and other organ-related morbidity and even mortality has been ascribed to the major haemodynamic effects of these tumours. Many factors affect the nature and intensity of these haemodynamic changes. The rarity of these tumours as well as their extremely varied clinical presentation preclude conduct of randomized-controlled trials that may provide evidence in terms of these factors and the ways to predict and control them. Many retrospective studies and case reports, however, do provide some insight into their haemodynamic behaviour. Factors such as tumour pathology, associated genetic syndromes, anatomical attributes and perioperative drug therapy affect the haemodynamics of patients with these unique tumours. Knowledge of these factors and their presumed and known association with haemodynamic behaviour of the patients is important during the perioperative care of these patients. The review focuses on the tumour-related, patient-related and the perioperative care-related factors that affect the haemodynamic behaviour of these patients during the surgical removal of these tumours.

Anesthesia management with short acting agents for bilateral pheochromocytoma removal in a 12-year-old boy

A 12-year-old boy with bilateral adrenal pheochromocytoma pretreated with furosemide, nifedipine, prazosin, and propranolol underwent surgical removal of the tumors. General anesthesia with desflurane, remifentanil infusion and thoracic epidural analgesia was performed. To control the blood pressure (BP), remifentanil up to 1 microg.kg(-1).min(-1) infusion rate, sodium nitroprusside, and esmolol infusions were administered successfully. Following the ligation of the adrenal veins, hemodynamic parameters were stable and neither inotropic support nor corticosteroid replacement was required. We concluded that remifentanil-based anesthesia combined with low-dose desflurane and thoracic epidural analgesia may reduce the need for vasoactive drugs in the anesthesia management of pheochromocytoma. This combination may not prevent the hemodynamic fluctuations during tumor manipulation, but appears to facilitate a rapid and stable postoperative recovery.