The effect of combined Epidural-general Anesthesia on Hemodynamic Instability during Pheochromocytoma and Paraganglioma Surgery: A multicenter retrospective cohort study

Abstract

Objectives: The purpose of this study was to compare the effects of combined epidural-general anesthesia with those of general anesthesia alone on hemodynamic instability (intraoperative hypotension and hypertensive crisis) during pheochromocytoma and sympathetic paraganglioma surgery. Methods: A total of 119 patients' medical records were reviewed who were diagnosed as having pheochromocytoma and sympathetic paraganglioma on the basis of histological findings. Intraoperative hypotension was defined as a mean blood pressure < 60 mmHg or a decrease > 30% in baseline systolic blood pressure after adrenal vein ligation. Hypertensive crisis was defined as a systolic blood pressure > 200 mmHg or an increase > 30% in baseline systolic blood pressure during the operation. The predictor variables for intraoperative hypotension and hypertensive crisis were analyzed with logistic regression models. Data were presented as adjusted odds ratio with 95% confidence interval. Results: The independent predictors of intraoperative hypotension were an increased attenuation number on unenhanced computed tomography (1.112 [1.009-1.226], p = 0.033), a high baseline mean blood pressure (1.063 [1.012-1.117], p = 0.015), and the combined epidural-general anesthesia (5.439 [1.410-20.977], p = 0.014). In contrast, an increased attenuation number on unenhanced computed tomography was the only independent predictor of hypertensive crisis (1.087 [1.021-1.158], p = 0.009). Conclusions: The combined epidural-general anesthesia was not effective in attenuating hypertensive responses, but could have exacerbated intraoperative hypotension. These findings should be taken into account before selecting the anesthetic technique in pheochromocytoma and sympathetic paraganglioma surgery.

Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis

“…The characteristics of included studies were shown in Table 1 . These 3 studies were published from 2018 to 2020, performed in China, [ 18 ] Korea, [ 16 ] and America, [ 17 ] respectively. The surgery types of the included studies were open surgery of pheochromocytoma, [ 18 ] open surgery of pheochromocytoma or paraganglioma, [ 17 ] and laparoscopic or open surgery of pheochromocytoma or paraganglioma, [ 16 ] respectively.…”

Anesthetic Management of Pheochromocytoma in Pediatric Patient—Case Report

“…However, epidural anesthesia in laparoscopy may not be appropriate, as it only provides a segmental block, which would not give an adequate pain relief during gas insufflation to create pneumoperitoneum. Additionally, it was reported that the combined epidural-general anesthesia during laparoscopy was not effective in attenuating hypertensive responses, and could have exacerbated intraoperative hypotension [12].…”

Perioperative use of thoracic epidural anaesthesia, dexmedetomidine and magnesium sulphate infusion in a dog undergoing neuroendocrine tumour resection

“…The volume administered was estimated considering the percentage of the spinal cord to be blocked, according to the mathematical model proposed by Otero et al 42 Reducing the systemic vascular resistance (SVR), the combination of epidural and general anaesthesia can decrease the need for vasodilatory drugs and has been associated with a lower risk of postoperative complications in human patients with PCC. 43,44 Epidural anaesthesia can also exacerbate intraoperative hypotension after tumour removal, 45 although this could be counteracted reducing the expired fraction of inhalant anaesthetic. 46,47 α 2 -adrenoceptor agonists (i.e., medetomidine or DEX) cause a dose-dependent increase of SVR and a decrease in CI.…”

“…Reducing the systemic vascular resistance (SVR), the combination of epidural and general anaesthesia can decrease the need for vasodilatory drugs and has been associated with a lower risk of postoperative complications in human patients with PCC 43,44 . Epidural anaesthesia can also exacerbate intraoperative hypotension after tumour removal, 45 although this could be counteracted reducing the expired fraction of inhalant anaesthetic 46,47 …”

“…The median (range) end-expiratory isoflurane concentration during surgery was 1.1% (0.9-1.2), end-expiratory carbon dioxide pressure 45 mmHg (38)(39)(40)(41)(42)(43)(44)(45), MAP 70 (55-110), CI 4.1 L/min/m 2 (3.8-4.7) and PPV 14% . No arrhythmias were detected, and no rescue analgesia was needed during anaesthesia.…”