PRE-OPERATIVE Chapters 13 and 14 – Learning from Experience

PERI-OPERATIVE

Chapter 13

Pheochromocytoma Post-operative Diagnosis

Vasanthi-Vidyasagaran

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

Case 1

A 25-year-old man assessed under ASA I was posted for a hydrocele surgery. He had no comorbidities and all his investigations were within normal limits. He was taken up under spinal anaesthesia. Baseline PR= 76/min, and BP=130/80 mmHg.

IV ringer lactate was started and spinal was given with 2.5 ml .5% Bupivacaine in L3-L4 space with a 25G Quincke needle. After about 15 minutes, his BP dropped to 90/60. Ephedrine 6 mg was administered along with increase in rate of IV fluid infusion. The BP immediately shot up to 160/110 and the patient started complaining of headache. He was reassured and injection Midazolam 1+1 mg was given IV. Oxygen was on flow.

Surgery was completed in 40 minutes and the patient was shifted to the post-operative ward. BP remained at 160/110 and he still complained of persistent headache. Considering it to be a post-dural puncture headache, he was adequately hydrated and advised to lie down. Routine analgesics (NSAID, and Tramadol) were prescribed.

The anaesthesiologist examined the patient on the first post-operative day and found that his BP was 180/110. The nature of his headache was not that of PDPH, but throbbing. Antihypertensive treatment was advised. With lowering of mean arterial blood pressure using calcium channel blockers, his headache got better. However, mean arterial pressure was greater than 100 mm Hg.

Considering this young man to be a case of secondary hypertension, he was investigated further. The physician eventually diagnosed him as a case of Pheochromocytoma.

Case 2

A 56-year-old man was posted for laparoscopic removal of adrenal mass, reviewed by an endocrinologist, and investigated. Urinary catecholamines were negative. Biopsy revealed a benign lesion. Precautions were taken in spite of negative results for Pheochromocytoma.

There were no serious hemodynamic fluctuations during anaesthetic induction and maintenance. BP was maintained at 130/80, HR around 80/min, in sinus rhythm. Surgery was uneventful. Towards the end, after removal of the tumour, blood pressure began to rise slowly to 170/100. Analgesia top up with Morphine 5 mg was administered, as an addition to transverse abdominal block and systemic analgesia with IV Paracetamol 1 gm and IV Fentanyl 100 mcg. Diltiazem 5 mg was given during extubation after administration of reversal agent. Despite this, blood pressure remained high at 210/110.

Infusion of IV Clonidine was commenced to control BP. Arterial line was placed. There was a high suspicion of the tumour to be Pheochromocytoma. Patient was shifted to HDU for further management. Pathology examination of the operated specimen came back as positive for suspected diagnosis.

Discussion

Pheochromocytoma is a not so common endocrine tumour. Clinical presentation can be atypical. Secreting tumours have high urinary catecholamines (CA), and symptoms due to raised CA include headache, chest pain, palpitations, diaphoresis, mostly episodic events which are often ignored by patients. Serious clinical presentations include bleeding, coronary or cerebrovascular events.

Non-secreting tumours are considered benign, however may pose problems under the stress of surgery and anaesthesia, post manipulation and release of catecholamines into circulation. This can be a nightmare to manage. Anticipation and vigilant control early on can help control and prevent catastrophic events.

Persistent tachycardia and hypertension in perioperative period should not be ignored. Common things being common, first rule out inadequate pain relief, hydration status, anxiety, sepsis, and primary hypertension. Secondary causes such as malignant hyperthermia, thyroid crisis, carcinoid syndrome and Pheochromocytoma, should also be considered.

Pheochromocytoma can also be extra adrenal (called paraganglioma,) and can arise in any portion of the paraganglion system, most commonly sub diaphragmatic. Hence in any tumour manipulation, one has to be vigilant and look for haemodynamic changes.

Persistent headache associated with hypertension is a serious warning sign. And this may get ignored if blood pressure monitoring is not done after spinal in the post-operative period.

Cornerstone of diagnosis of Pheochromocytoma is measurement of Norepinephrine, Epinephrine and their metabolic products in the urine. They may present in emergency situations like acute abdomen, trauma, and even during caesarean section. In such times, lateral thinking is vital. Glucose level monitoring is important in these cases due to high circulating catecholamine levels.

These tumours may be silent and asymptomatic, but turn catastrophic when stimulated.

References

  1. Myklejord DJ. Undiagnosed Pheochromocytoma: The Anesthesiologist Nightmare. Clin Med Res. 2004;2:5962.
  2. Dr R, Lenders JWM, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma: Update on Disease Management. Ther Adv in Endo and Metab. 2012;3(1):11-26.
  3. Youn Hee Lim, Won Ji Rhee, So Ron Choi, Sang Won Park, and Chan Jong Chung Intraoperative hypertension in a patient with undiagnosed Pheochromocytoma under spinal anesthesia. Korean J Anesthesiol. 2011;61(5):439440.

Not everyone is given a chance to serve humanity as a doctor and especially as an Anaesthesiologist. Feel privileged and blessed to be one.

PERI-OPERATIVE

Chapter 14

Postpartum Haemorrhage

A 40-year-old primi parous woman was admitted for an elective LSCS. All her investigations were within normal limits. On examination, her pulse rate was 102 beats/min, BP – 110/70 mm Hg, and lungs were clear. Airway assessment was done and no difficulty was anticipated. After an overnight NPO status she was taken up for surgery under spinal anaesthesia.

Under strict aseptic precautions, a subarachnoid block with 1.8 ml 0.5% Bupivacaine with 25 microgram Fentanyl was given in L3-L4 space using a 26G Quincke needle. Level achieved was T6. Injection Ephedrine 6 mg was used to control the initial hypotension. Blood pressure was maintained at 110/70 ml of Hg.

After the baby was delivered, Oxytocin 15 U IV was given in 500ml saline. The uterus was not contracting, hence, methergine was given. The uterus was still lax, and prostaglandin was given deep

I.M. But the uterus did not respond to uterotonics and she started bleeding heavily. Within a matter of ten minutes, the patient had lost a considerable amount of blood, approximately 1.5 litres. The exact loss could not be calculated.

As the BP began to fall (80/50 mm Hg), anticipating further trouble, patient was quickly induced with Ketamine 80 mg, Fentanyl 100 microgram, and intubated with Succinylcholine 75 mg. A Dopamine infusion was started at 10 microgram/kg/min to maintain her systolic blood pressure around 90 mm Hg.

Large bore venous access was obtained and rapid blood transfusions with 6 units packed cells, 4 units FFP were given. B lynch suturing and internal iliac artery ligation were done to control the bleeding; however, it was not helpful in this patient. The surgeons had to resort to an obstetric hysterectomy. Patient was in a state of DIC at that point.

At the end of surgery, the patient was shifted to the PACU for elective post-operative ventilation. With Dopamine infusion, her pressures were maintained at 90/60 mm Hg.

Her urine output was approximately 20 ml/hr.

Post-operative investigations showed Hb-5 gm%, platelets-40,000/cu mm, D dimer positive. Repeat transfusions of 4 units packed cells, 4 adult units of platelets and 2 adult units of cryoprecipitate were done. Over the next 24 hours, Dopamine was tapered and the patient was extubated on post-operative day 3. She was discharged home in ten days with no cardiorespiratory issues. Timely interventions from all aspects saved our patient.

Discussion

This case highlights that what starts out as a routine caesarean section can at any time turn into an unexpected emergency, and every practicing anaesthetist must be prepared at all times. All obstetric patients should have back up for transfusions without any delay.

Management of obstetric haemorrhage involves a lot of anticipation and timely management to save the life of the mother. PPH may occur with normal coagulation, or due to coagulopathy, and what starts as normal coagulation may slip into DIC. Causes include atonic uterus, retained placenta, tissue trauma, and existing coagulation abnormalities.

Management can be challenging depending on

  1. Preoperative condition of the patient
  2. Availability of resources and preparedness of the team
  3. Rate of blood loss
  4. Response of patient to the blood loss
  5. Tolerance of patient to massive blood replacement
  6. How quickly vitals get restored (response to treatment)

Obstetric haemorrhage is usually very brisk and hence time is life. Exact quantification of blood loss is difficult. Volume of blood clots observed reflects only about half the volume of blood actually lost, and if DIC were to set in it is quite impossible to predict the outcome. It is of extreme importance to STOP the ongoing bleed as early as possible.

Rapid assessment and early commencement of treatment is essential to prevent effects of hypovolemia to set in. Replace blood loss with blood. Anticipate and gain large intravenous line access before onset of DIC and collapse of vein. Transfusion of blood products, packed cells: fresh frozen plasma: platelets in a ratio of 2: 1:1 is advisable. Tranexamic acid as an adjuvant to reduce bleeding may be used.

Recombinant factor VIIa should be restricted to women with specific haematological disorders. Fresh whole blood transfusion (less than 24 hours old) may be considered. In the army during injuries in a battle field, fresh whole blood transfusion is used so that complications from lack of cofactors are prevented. Transfusion practices for haemorrhage have evolved in the past hundred years. There is a concept of walking blood bank pre-screened pool of donors readily available for donations, the main advantage being limiting the number of exposure to donor component blood products. Fresh whole blood also has all the blood components and usually given at room temperature and hence the risk of hypothermia is less. Stored whole blood does not have any advantage in this situation and hence not recommended.

Appropriate management with uterotonics and surgical therapy including bimanual compression, internal iliac artery ligation if necessary need to be initiated early.

Massive haemorrhage, followed by massive blood transfusion in the event of ongoing blood loss may easily tilt the balance of bodys coagulation process. Investigate DIC with suspicion and treat accordingly. Intense monitoring, including CVP and urine output become necessary. Associated hypothermia and acidosis must be addressed.

Patient must be reasonably stabilized prior to transfer to higher centre if needed. Transfer of critically ill patient involves its inherent risks. Expertise must be exercised at all levels.

Management in intensive care postoperatively to ensure support to vital organs, prevention of infections, thromboembolic phenomenon, and multi-organ failure is essential.

PPH need not necessarily occur only following C section. It can follow even a normal vaginal delivery. There should be multidisciplinary coordination and no time should be lost in diagnosing and initiating prompt management.

References

  1. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997;104(3):372-5.
  2. Price N, B-Lynch C. Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases. Int J Fertil Womens Med. 2005;50(4):148-63.
  3. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol. 2002;99(3):502-6.
  4. Dildy GA 3rd. postpartum hemorrhage: new management options. Clin Obstet Gynecol. 2002;45(2):330-44.
  5. Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27(1):200-10.
  6. Stainsby D, MacLennan S, Hamilton PJ. Management of massive blood loss: a template guideline. Br J Anaesth. 2000;85(3):487-91.
  7. Lutomski J, Byrne B, Devane D, Greene R. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study. BJOG. 2012;119(3):306-14.

Nothing is Routine in anaesthesia practice expect the unexpected and be Prepared Always.

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