The use of vasopressin to treat catecholamine-resistant hypotension after phaeochromocytoma removal

Management of Patients with Treatment of Pheochromocytoma: A Critical Appraisal

Simple Summary

Preoperative medical preparation with an alpha blockade has been implemented early 1960s to prevent intraoperative hemodynamic instability and consequently decrease morbi-mortality in patients at a high risk of complications. Indeed, surgery at that time consisted of open adrenalectomies with a high morbidity and mortality rate. Current clinical guidelines are based on these early experiences. However, emerging technologies have permitted a drastic reduction of the morbi-mortality rate in patients treated for pheochromocytoma. However, the clinical guidelines have not evolved at the same rate. The aim of this systematic review is to assess the evolution of the management of pheochromocytomas and to appraise the current clinical guidelines to the current clinical practices.

Abstract

The management of pheochromocytomas has significantly evolved these last 50 years, especially with the emergence of new technologies such as laparoscopic procedures in the 1990s. A preoperative blockade using antihypertensive medications to prevent intraoperative hemodynamic instability and cardiocirculatory events is recommended by current clinical guidelines. However, these guidelines are still based on former experiences and are subject to discussion in the scientific community. The aim of this systematic review was to assess the evolution of the management of pheochromocytomas. Laparoscopic procedure is established as the standard of care in current practices. Preoperative medical preparation should be questioned because it does not significantly improve intraoperative events or the risk of postoperative complications in current clinical practice. Current clinical recommendations should be revised and upgraded to current clinical practices.

Anaesthetic challenges in perioperative management of thoracic paraganglioma in an 8-year-old child

Pheochromocytomas (PCC) are catecholamine-secreting tumours that arise from chromaffin cells of the sympathoadrenal system. These rare catecholamine-secreting tumours arising from adrenal glands are termed as PCC and those from extra--adrenal sites are termed paraganglioma (PGL). Thoracic PGL is very rarely found. we report the anaesthetic challenges and management of an 8-year-old child with functional thoracic PGL and its successful outcome.

Pheochromocytoma resection: Current concepts in anesthetic management

Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.

Anesthetic Management of Pheochromocytoma

The anesthetic management of pheochromocytoma is complicated and challenging. However, preoperative pharmacologic preparation has greatly improved perioperative outcome, and modern anesthetic drugs combined with advanced monitoring contribute to intraoperative stability. There is great regional and international variation in which intraoperative anesthetic technique is employed and there are little data to suggest one approach over another. Nevertheless, most management principles are universal. Progress lies in improved data collection that is increasingly available with electronic anesthesia information systems.

Adverse drug reactions in patients with phaeochromocytoma: incidence, prevention and management

The dangers of phaeochromocytomas are mainly due to the capability of these neuroendocrine tumours to secrete large quantities of vasoactive catecholamines, thereby increasing blood pressure and causing other related adverse events or complications. Phaeochromocytomas are often missed, sometimes only becoming apparent during therapeutic interventions that provoke release or interfere with the disposition of catecholamines produced by the tumours. Because phaeochromocytomas are rare, evidence contraindicating use of specific drugs is largely anecdotal or based on case reports. The heterogeneous nature of the tumours also makes adverse reactions highly variable among patients. Some drugs, such as dopamine D(2) receptor antagonists (e.g. metoclopramide, veralipride) and beta-adrenergic receptor antagonists (beta-blockers) clearly carry high potential for adverse reactions, while others such as tricyclic antidepressants seem more inconsistent in producing complications. Other drugs capable of causing adverse reactions include monoamine oxidase inhibitors, sympathomimetics (e.g. ephedrine) and certain peptide and corticosteroid hormones (e.g. corticotropin, glucagon and glucocorticoids). Risks associated with contraindicated medications are easily minimised by adoption of appropriate safeguards (e.g. adrenoceptor blockade). Without such precautions, the state of cardiovascular vulnerability makes some drugs and manipulations employed during surgical anaesthesia particularly dangerous. Problems arise most often when drugs or therapeutic procedures are employed in patients in whom the tumour is not suspected. In such cases, it is extremely important for the clinician to recognise the possibility of an underlying catecholamine-producing tumour and to take the most appropriate steps to manage and treat adverse events and clinical complications.

Vasopressin vs. terlipressin in the treatment of cardiovascular failure in sepsis

BACKGROUND

Arginine vasopressin (AVP) and terlipressin (TP) are increasingly used as adjunct vasopressors in the treatment of septic shock. Despite important pharmacological differences between the two drugs (e.g., receptor selectivity, effective half-life) the use of either substance is determined mainly by local availability and institutional inventory. We briefly describe the pathophysiology and pharmacology of septic shock relevant to the treatment with vasopressin analogues. In addition, differences in pharmacokinetics and pharmacodynamics between AVP and TP are discussed.

DISCUSSION

The current literature suggests that neither AVP nor TP should be administered in high doses in patients with septic shock. Furthermore, increasing evidence indicates that early administration of vasopressin analogues may improve outcome as compared to a last-resort treatment. Low-dose infusion of AVP (0.6-2.4 U/h) has been demonstrated to be a safe adjunct in the management of septic shock. The V2 agonistic effects of AVP may exert favorable effects on hepatosplanchnic, renal, pulmonary, and coronary perfusion. However, the higher V1 receptor selectivity of TP may prove more potent in restoring arterial blood pressure and avoiding rebound hypotension, while carrying the risk of sustained global and regional vasoconstriction after bolus injection.

CONCLUSIONS

Evidence from experimental studies and initial clinical reports suggests that continuous low-dose infusion of TP may stabilize hemodynamics in septic shock with reduced side effects. However, randomized, controlled trials are necessary to determine the role of bolus or continuous infusion of TP in the treatment of septic shock before this approach can be recommended for routine clinical use.

Vasopressin in shock states

PURPOSE OF REVIEW

There is growing evidence that in end-stage shock or during cardiac arrest, inappropriately low endogenous vasopressin plasma levels may be responsible for pathologic vasodilatation, inadequate organ perfusion, and poor outcome. The purpose of this article is to review recent publications featuring arginine vasopressin as a potent vasoconstrictor in various shock states such as systemic vasodilatation, severe hypovolemia, or cardiac arrest.

RECENT FINDINGS

Several retrospective investigations give evidence that vasopressin at a dosage of 2-6 U/h is effective in reversing catecholamine-resistant vasodilatory shock due to sepsis or after cardiopulmonary bypass, but prospective randomized controlled trials are warranted. In experimental hypovolemic cardiac arrest or therapy-resistant (irreversible) hypovolemic shock, vasopressin may be an intriguing therapy, although human evidence is not available. Animal data gives strong evidence that vasopressin given during cardiopulmonary resuscitation improves both return of spontaneous circulation and neurological outcome. Clinical experience on the use of vasopressin for in-hospital cardiopulmonary resuscitation with short response time showed equipotency with epinephrine; in patients with out-of-hospital ventricular fibrillation, vasopressin showed improved 24 h survival in comparison with epinephrine. After the large European multicenter study completed in summer 2002, we will hopefully be able to better determine the role of vasopressin versus epinephrine in the management of adult cardiac arrest.

SUMMARY

Vasopressin administration is emerging as a rational and promising therapy in the management of various shock states and cardiac arrest.

Arginine vasopressin as a rescue vasopressor agent in the operating room

PURPOSE OF REVIEW

This review gives an overview of the current knowledge and research on the use of arginine vasopressin in cardiac arrest and severe shock states.

RECENT FINDINGS

Animal models have revealed the effectiveness of arginine vasopressin in increasing vital organ perfusion during cardiopulmonary resuscitation. A multicentre trial compared arginine vasopressin and epinephrine in out-of-hospital cardiac arrest, and documented a significant improvement in hospital discharge rates in arginine vasopressin-treated (up to 2 x 40 IU) patients with asystole, and a significant benefit of the combined administration of arginine vasopressin and epinephrine on hospital discharge, irrespective of the underlying electrocardiographic rhythm. The stabilization of advanced shock states unresponsive to conventional therapy can be achieved by supplementary arginine vasopressin (1-4 IU/h). A randomized, controlled trial found that the combined infusion of arginine vasopressin and norepinephrine was superior to norepinephrine alone in reversing advanced vasodilatory shock. Furthermore, the successful employment of arginine vasopressin in uncontrolled haemorrhagic shock and other shock states, such as anaphylaxis, hypotension during spinal/epidural anaesthesia, postcardiotomy shock, acute brain injury, brain-dead organ donors, perioperative hypotension in patients chronically treated with angiotensin-converting enzyme inhibitors, shock after pheochromocytoma surgery, and carcinoid crisis have been reported.

SUMMARY

Whereas arginine vasopressin in combination with epinephrine can significantly increase hospital discharge in cardiac arrest, arginine vasopressin combined with catecholamines improved haemodynamics in vasodilatory and haemorrhagic shock, but effects on outcome remain unknown. Nonetheless, in the perioperative setting, arginine vasopressin may already be considered as a potent adjunct vasopressor agent in advanced shock states unresponsive to conventional therapy.