PHEOCHROMOCYTOMA — HIGH-YIELD ANESTHESIA NOTES 🧠 CORE Catecholamine-secreting tumor of adrenal chromaffin tissue. Extra-adrenal sympathetic-chain tumor → paraganglioma. Associated syndromes: MEN 2, VHL, NF-1. Classic triad: HEADACHE + SWEATING + TACHYCARDIA Suspect with young/resistant HTN, paroxysmal spells, adrenal mass, or familial syndrome. All pheochromocytomas have malignant potential → metastasis defines malignancy. 🔬 DIAGNOSIS Low suspicion: 24-h urinary fractionated metanephrines/catecholamines High suspicion: Plasma fractionated metanephrines/catecholamines Plasma/urinary metanephrines >2× ULN → diagnostic Then localize: CT / MRI / MIBG scan --- 🩺 PREOPERATIVE OPTIMIZATION GOAL ↓ Catecholamine effects + restore intravascular volume α-BLOCKADE FIRST Phenoxybenzamine: 10 mg BD → titrate Selective α1: prazosin, doxazosin, terazosin Usually 7–14 days pre-op 🎯 TARGETS Sitting BP <130/80 mmHg Standing SBP >90 mmHg HR sitting 60–70/min HR standing 70–80/min ❤️ β-BLOCKER Only AFTER adequate α-blockade. Never β-block first → unopposed α → severe hypertension. Indication: persistent tachycardia. OTHER CCB: nicardipine / amlodipine / nifedipine High-salt diet + adequate oral fluids → reverse volume contraction Metyrosine → ↓ catecholamine synthesis; useful in severe/high catecholamine states Optimize catecholamine cardiomyopathy, arrhythmia, ACS --- 💉 INTRAOPERATIVE ANESTHESIA MONITORING Arterial line BEFORE induction Large-bore IV access Central line selectively, not routine TEE/PAC → severe ventricular dysfunction INDUCTION Smooth + deep + controlled Benzodiazepine/dexmedetomidine → reduce anxiety/catecholamine surge Propofol / etomidate → acceptable AVOID KETAMINE Avoid pancuronium Desflurane → may cause tachycardia 🚨 CATECHOLAMINE SURGES Common during: Induction → intubation → positioning → tumor manipulation Avoid triggers such as metoclopramide. 🔥 BEFORE TUMOR VEIN LIGATION Expect severe hypertension. Preferred short-acting agents: Nicardipine Clevidipine Nitroprusside Nitroglycerin Esmolol → tachycardia MgSO₄ Load 2–4 g Infusion 1–2 g/h Vasodilator + ↓ catecholamine release --- 🩸 AFTER VEIN LIGATION Catecholamine suddenly ↓ → vasodilation + hypotension Management 1. Stop vasodilators 2. Ensure adequate volume 3. Vasopressors: Phenylephrine → commonly first choice Norepinephrine / epinephrine if needed Vasopressin / methylene blue → refractory vasoplegia 💡 Vasopressor choice can be guided by the predominant catecholamine phenotype. --- 🍬 GLUCOSE BEFORE RESECTION Catecholamines → ↑ insulin resistance + ↓ insulin secretion → hyperglycemia AFTER RESECTION Catecholamines ↓ → rebound hyperinsulinemia → hypoglycemia ➡️ Monitor glucose q1–2 h for first 6–24 h. --- 🏥 POSTOPERATIVE Usually ICU/high-dependency monitoring Watch for: Hypotension Persistent hypertension Arrhythmias Hypoglycemia ~50% may remain hypertensive for 1–3 days Catecholamine levels initially remain elevated, then decline. --- ⚡ 10-SECOND VIVA RECALL PHEO = α → volume → β → smooth anesthesia → control surges → vein ligation = hypotension → glucose watch NEVER: β-blockade before α-blockade. ARTERIAL LINE: before induction. BIGGEST INTRAOP PROBLEM: catecholamine-driven hypertension. BIGGEST POST-LIGATION PROBLEM: vasoplegic hypotension. POST-OP PEARL: rebound hypoglycemia. Create handwritten style notes image

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