Excision of pheochromocytoma - Revision history

Tony.Wang: added phentolamine IV

2025-01-07T16:53:03Z

added phentolamine IV

Mitchel.DeVita at 08:42, 30 May 2022

2022-05-30T08:42:15Z

← Older revision		Revision as of 01:42, 30 May 2022
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	* ± Echocardiogram to assess signs of heart failure, Takotsubo cardiomyopathy, or to diagnose cardiac paragangliomas		* ± Echocardiogram to assess signs of heart failure, Takotsubo cardiomyopathy, or to diagnose cardiac paragangliomas
	*Capillary glucose to test temporary insulin resistance		*Capillary glucose to test temporary insulin resistance
			*CBC to assess baseline hemoglobin and platelet values
			*CMP to identify electrolyte abnormalities such as hypernatremia or hypokalemia
			*Plasma metanephrines (Normetanephrine, Norepinephrine, Epinephrine , Dopamine)

	===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===		===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===
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	===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===		===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===

	*Open laparotomy may require epidural pain control		*Open laparotomy may require epidural pain control. Extreme caution must be utilized in epidural dosing as hemodynamic changes can occur rapidly during surgery. Frequently the epidural is placed preoperatively and not utilized until hemodynamic stability with the tumor removed is achieved.
	*Laparoscopic and particularly single-incision retroperitoneal support rarely require epidural pain management. Pain can be controlled using IV and PO pain medications.		*Laparoscopic and particularly single-incision retroperitoneal support rarely require epidural pain management. Pain can be controlled using IV and PO pain medications.

Chris.Rishel at 06:30, 5 April 2022

2022-04-05T06:30:47Z

← Older revision		Revision as of 23:30, 4 April 2022
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	\|-		\|-
	\|Neurologic		\|Neurologic
	\|* Investigate headaches and fatigue		\|
			* Investigate headaches and fatigue
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular

Chris.Rishel at 06:30, 5 April 2022

2022-04-05T06:30:30Z

Show changes

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:44:02Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:44, 21 February 2022
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	* Patients may present with catecholamine-induced, Takotsubo, or dilated cardiomyopathy<ref>{{Cite journal\|last=Prejbisz\|first=Aleksander\|last2=Lenders\|first2=Jacques W.M.\|last3=Eisenhofer\|first3=Graeme\|last4=Januszewicz\|first4=Andrzej\|date=2011\|title=Cardiovascular manifestations of phaeochromocytoma\|url=https://journals.lww.com/00004872-201111000-00001\|journal=Journal of Hypertension\|language=en\|volume=29\|issue=11\|pages=2049–2060\|doi=10.1097/HJH.0b013e32834a4ce9\|issn=0263-6352\|via=}}</ref><ref>{{Cite journal\|last=Gu\|first=Yu Wei\|last2=Poste\|first2=Jennifer\|last3=Kunal\|first3=Mehta\|last4=Schwarcz\|first4=Monica\|last5=Weiss\|first5=Irene\|date=2017\|title=Cardiovascular Manifestations of Pheochromocytoma\|url=https://journals.lww.com/00045415-201709000-00004\|journal=Cardiology in Review\|language=en\|volume=25\|issue=5\|pages=215–222\|doi=10.1097/CRD.0000000000000141\|issn=1061-5377\|via=}}</ref>		* Patients may present with catecholamine-induced, Takotsubo, or dilated cardiomyopathy<ref>{{Cite journal\|last=Prejbisz\|first=Aleksander\|last2=Lenders\|first2=Jacques W.M.\|last3=Eisenhofer\|first3=Graeme\|last4=Januszewicz\|first4=Andrzej\|date=2011\|title=Cardiovascular manifestations of phaeochromocytoma\|url=https://journals.lww.com/00004872-201111000-00001\|journal=Journal of Hypertension\|language=en\|volume=29\|issue=11\|pages=2049–2060\|doi=10.1097/HJH.0b013e32834a4ce9\|issn=0263-6352\|via=}}</ref><ref>{{Cite journal\|last=Gu\|first=Yu Wei\|last2=Poste\|first2=Jennifer\|last3=Kunal\|first3=Mehta\|last4=Schwarcz\|first4=Monica\|last5=Weiss\|first5=Irene\|date=2017\|title=Cardiovascular Manifestations of Pheochromocytoma\|url=https://journals.lww.com/00045415-201709000-00004\|journal=Cardiology in Review\|language=en\|volume=25\|issue=5\|pages=215–222\|doi=10.1097/CRD.0000000000000141\|issn=1061-5377\|via=}}</ref>
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|		\|
	* Classify obstructive or restrictive lung disease		* Classify obstructive or restrictive lung disease

Nkamdar at 18:43, 2 September 2021

2021-09-02T18:43:57Z

← Older revision		Revision as of 11:43, 2 September 2021
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	}}The '''excision of a pheochromocytoma''' is a variant of an [[adrenalectomy]], which is the removal of one or both adrenal glands. When the tumor being removed is a [[pheochromocytoma]], careful preoperative optimization and intraoperative management are required to ensure hemodynamic stability during the procedure.		}}The '''excision of a pheochromocytoma''' is a variant of an [[adrenalectomy]], which is the removal of one or both adrenal glands. When the tumor being removed is a [[pheochromocytoma]], careful preoperative optimization and intraoperative management are required to ensure hemodynamic stability during the procedure.

	Surgical resection can be performed via open laparotomy, laparoscopic transabdominal, laparoscopic retroperitoneal, or single incision laparoscopic retroperitoneal approaches, each of which has different indications, advantages and disadvantages, as well as unique line and monitoring choices.		Surgical resection can be performed via open laparotomy, laparoscopic transabdominal, laparoscopic retroperitoneal, or single incision laparoscopic retroperitoneal approaches, each of which has different indications, advantages and disadvantages, as well as unique line and monitoring choices.

	== Preoperative management ==		== Preoperative management ==

Chris.Rishel: Added epidural to open approach

2021-08-02T14:08:35Z

Added epidural to open approach

← Older revision		Revision as of 07:08, 2 August 2021
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	\|-		\|-
	\|'''Pain management'''		\|'''Pain management'''
	\|		\|Epidural
	\|Oral and IV pain medications		\|Oral and IV pain medications
	\|Oral pain medications		\|Oral pain medications

Chris.Rishel at 02:56, 2 August 2021

2021-08-02T02:56:15Z

← Older revision		Revision as of 19:56, 1 August 2021
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	\|-		\|-
	\|'''Pain management'''		\|'''Pain management'''
	\|~~Epidural~~		\|
	\|Oral and IV pain medications		\|Oral and IV pain medications
	\|Oral pain medications		\|Oral pain medications

Chris.Rishel: Added epidural to open approach

2021-08-02T02:41:45Z

Added epidural to open approach

← Older revision		Revision as of 19:41, 1 August 2021
Line 191:		Line 191:
	\|-		\|-
	\|'''Pain management'''		\|'''Pain management'''
	\|		\|Epidural
	\|Oral and IV pain medications		\|Oral and IV pain medications
	\|Oral pain medications		\|Oral pain medications

Chris.Rishel at 23:25, 1 August 2021

2021-08-01T23:25:11Z

← Older revision		Revision as of 16:25, 1 August 2021
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	\|-		\|-
	\|'''Pain management'''		\|'''Pain management'''
	\|~~Epidural~~		\|
	\|Oral and IV pain medications		\|Oral and IV pain medications
	\|Oral pain medications		\|Oral pain medications

← Older revision		Revision as of 09:53, 7 January 2025
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	*± Insulin infusion to treat hyperglycemia		*± Insulin infusion to treat hyperglycemia
	*Diluted push syringes of vasodilators and vasopressors to adjust blood pressure with sudden changes to blood pressure during catecholamine surges during induction and tumor manipulation.		*Diluted push syringes of vasodilators and vasopressors to adjust blood pressure with sudden changes to blood pressure during catecholamine surges during induction and tumor manipulation.
			*IV phentolamine

	===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===		===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===
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	*Consider pre-induction arterial line as catecholamine surge can occur during mask ventilation and intubation.		*Consider pre-induction arterial line as catecholamine surge can occur during mask ventilation and intubation.
	**Some centers describe a conducting a phenylephrine titration prior to induction to test the adequacy of α-blockade<ref>{{Cite journal\|last=Saksa\|first=Dane\|last2=Shuch\|first2=Brian\|last3=Donahue\|first3=Timothy\|last4=Cusumano\|first4=Lucas\|last5=Yu\|first5=Run\|last6=Alapag\|first6=Catharina\|last7=Kamdar\|first7=Nirav\|date=2021-01-14\|title=Telemedicine-Based Perioperative Management of Pheochromocytoma in a Patient With Von Hippel Lindau Disease: A Case Report\|url=https://pubmed.ncbi.nlm.nih.gov/33512909\|journal=A&A Practice\|volume=15\|issue=1\|pages=e01378\|doi=10.1213/XAA.0000000000001378\|issn=2575-3126\|pmid=33512909}}</ref>		**Some centers describe a conducting a phenylephrine titration prior to induction to test the adequacy of α-blockade<ref>{{Cite journal\|last=Saksa\|first=Dane\|last2=Shuch\|first2=Brian\|last3=Donahue\|first3=Timothy\|last4=Cusumano\|first4=Lucas\|last5=Yu\|first5=Run\|last6=Alapag\|first6=Catharina\|last7=Kamdar\|first7=Nirav\|date=2021-01-14\|title=Telemedicine-Based Perioperative Management of Pheochromocytoma in a Patient With Von Hippel Lindau Disease: A Case Report\|url=https://pubmed.ncbi.nlm.nih.gov/33512909\|journal=A&A Practice\|volume=15\|issue=1\|pages=e01378\|doi=10.1213/XAA.0000000000001378\|issn=2575-3126\|pmid=33512909}}</ref>
	*Catecholamine surges can occur during the following intraoperative periods<ref>{{Cite journal\|last=Joris\|first=J. L.\|last2=Hamoir\|first2=E. E.\|last3=Hartstein\|first3=G. M.\|last4=Meurisse\|first4=M. R.\|last5=Hubert\|first5=B. M.\|last6=Charlier\|first6=C. J.\|last7=Lamy\|first7=M. L.\|date=1999\|title=Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma\|url=https://pubmed.ncbi.nlm.nih.gov/9895059\|journal=Anesthesia and Analgesia\|volume=88\|issue=1\|pages=16–21\|doi=10.1097/00000539-199901000-00004\|issn=0003-2999\|pmid=9895059\|via=}}</ref>: intubation < Positioning < Insufflation < tumor manipulation		*Catecholamine surges can occur during the following intraoperative periods<ref>{{Cite journal\|last=Joris\|first=J. L.\|last2=Hamoir\|first2=E. E.\|last3=Hartstein\|first3=G. M.\|last4=Meurisse\|first4=M. R.\|last5=Hubert\|first5=B. M.\|last6=Charlier\|first6=C. J.\|last7=Lamy\|first7=M. L.\|date=1999\|title=Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma\|url=https://pubmed.ncbi.nlm.nih.gov/9895059\|journal=Anesthesia and Analgesia\|volume=88\|issue=1\|pages=16–21\|doi=10.1097/00000539-199901000-00004\|issn=0003-2999\|pmid=9895059\|via=}}</ref>: intubation < Positioning < Insufflation < tumor manipulation
	*Treat and control hypertension prior to adrenal vein ligation.		*Treat and control hypertension prior to adrenal vein ligation.
	**Start with vasodilators (nitroprusside, nitroglycerine, nicardipine, clevidipine) and then supplement with short-acting beta-blockade (esmolol)		**Start with vasodilators (nitroprusside, nitroglycerine, nicardipine, clevidipine) and then supplement with short-acting beta-blockade (esmolol)
			**Consider phentolamine IV (1 mg push at a time)
	*Surgery team should communicate with anesthesia team when the adrenal vein has been identified and prior to clamping		*Surgery team should communicate with anesthesia team when the adrenal vein has been identified and prior to clamping
	**Anesthesia team should load patients with fluid prior to adrenal vein identification		**Anesthesia team should load patients with fluid prior to adrenal vein identification