The Effect of Alpha-Adrenergic Blockade on Cardiac Performance and Tissue Oxygen Delivery During Excision on Pheochromocytoma

Roizen, Michael F.; Tk, Hunt; Beuapre, P. N.; Kremer, P. J.; Firmin, Richard K.; Chang, C. Ning; Alpert, Ricki A.; Thomas, Chinnamma; Tyrrell, James; Cahalan, M. K.

doi:10.1097/00132586-198408000-00068

Cited by 19 publications

(34 citation statements)

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“…This improved prognosis is currently attributed to the widespread preoperative administration of vasodilating drugs and large fluid volumes, even in patients with normal or borderline elevation of catecholamine levels (5,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). Nevertheless, none of these practices are evidence based, and to our opinion, a critical review of the available literature does not support this dogma.…”

Section: Historical Backgroundmentioning

confidence: 99%

“…The subsequent sudden intraoperative withdrawal of vasopressors following pheochromocytoma resection was believed to cause abrupt relaxation of the vascular bed, in turn resulting in hypotension and shock unless the reduced blood volume was restored (13)(14)(15). This led to the assumption that optimal preoperative care had to include preoperative vasodilation of the previously constricted vascular compartment by a vasodilating drug along with restoring blood volume by major fluid infusion (5,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30).…”

Section: Historical Backgroundmentioning

confidence: 99%

“…-Increasing depth of anesthesia and muscle relaxation is a common anesthetic practice to reduce intraoperative increases in blood pressure (16,28,32,50). As mentioned earlier, BIS-guided anesthesia has not been studied in pheochromocytoma surgery (51).…”

Section: Intraoperative Hypotensive Drugsmentioning

confidence: 99%

“…Hypotension following pheochromocytoma removal is definitively controlled within a few hours following surgery in most patients (5,16,19,22,28,30,31). Anecdotal reports of patients requiring a 48 h vasopressive support are available (1,5).…”

Section: Postoperative Carementioning

confidence: 99%

“…Anecdotal reports of patients requiring a 48 h vasopressive support are available (1,5). High blood pressure requiring specific care has been reported to persist for a variable duration in 40% of patients (5,16,19,22,28,30,31). Blood glucose concentration should be monitored for at least 24 h (6, 7).…”

Section: Postoperative Carementioning

confidence: 99%

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Point of controversy: perioperative care of patients undergoing pheochromocytoma removal–time for a reappraisal?

Lentschener¹,

Gaujoux²,

Tesnière³

et al. 2011

European Journal of Endocrinology

126

143

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Adrenalectomy for pheochromocytoma is reported with a mortality close to zero in recent studies. The dogma of preoperative fluid and hypotensive drug administrations is widely applied in patients scheduled for pheochromocytoma removal and is assumed to have a beneficial effect on operative outcomes. This paradigm is only based on historical studies of non-standardized practices and criteria for efficacy, with no control group. Pre-and intraoperative hypovolemia have never been demonstrated in patients scheduled for pheochromocytoma removal. Recent improvements in outcome of patients undergoing adrenalectomy for pheochromocytoma could also be the result of improvement in surgical techniques and refinement in anesthetic practices. Whether better knowledge of the disease, efficiency of available intravenous short-acting vasoactive drugs, and careful intraoperative handling of the tumor make it possible to omit preoperative preparation in most patients scheduled for pheochromocytoma removal is presently questionable. We reviewed available literature in this respect.

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Section: Historical Backgroundmentioning

confidence: 99%

Section: Historical Backgroundmentioning

confidence: 99%

Section: Intraoperative Hypotensive Drugsmentioning

confidence: 99%

Section: Postoperative Carementioning

confidence: 99%

Section: Postoperative Carementioning

confidence: 99%

See 3 more Smart Citations

Point of controversy: perioperative care of patients undergoing pheochromocytoma removal–time for a reappraisal?

Lentschener¹,

Gaujoux²,

Tesnière³

et al. 2011

European Journal of Endocrinology

126

143

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Sensitivity of Diagnostic and Localization Tests for Pheochromocytoma in Clinical Practice

Witteles¹,

Kaplan²,

Roizen³

2000

Arch Intern Med

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The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

et al. 2019

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Background Hemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications. Methods Ten patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters. Results Applying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg −1 h −1 , p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min −1 m −2 , p = 0.005; HIAT: 2.08 vs. 2.56 l min −1 m −2 , p = 0.225). Conclusions As vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course. Trial registration: ClinicalTrials.gov, Identifier: NCT01425710.

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The Effect of Alpha-Adrenergic Blockade on Cardiac Performance and Tissue Oxygen Delivery During Excision on Pheochromocytoma

Cited by 19 publications

References 0 publications

Point of controversy: perioperative care of patients undergoing pheochromocytoma removal–time for a reappraisal?

Point of controversy: perioperative care of patients undergoing pheochromocytoma removal–time for a reappraisal?

Sensitivity of Diagnostic and Localization Tests for Pheochromocytoma in Clinical Practice

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

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