Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

Chapter 76. Pheochromocytoma

Neelima Myneni, MD

  • Tumors of the adrenal medulla that produce, secrete, and store catecholamines
  • Norepinephrine is predominantly secreted along with small amounts of epinephrine, and occasionally dopamine
  • Perioperative mortality has been reported to be as high as 45% from cardiovascular causes, and directly correlates with tumor size and degree of catecholamine secretion. With appropriate management, mortality is very low
  • Surgical exploration is curative in 95% of cases, with reduction in mortality to 3%
  • Rule of 10s: 10% are malignant, 10% are extra-adrenal, 10% are bilateral
  • Occasionally associated with syndromes: MEN IIA, MEN IIB, von Hippel-Lindau disease, or in rare cases, Von Recklinghausen’s disease, tuberous sclerosis, and Sturge-Weber syndrome
  • Typical presentation is a young adult in 30s to 50s with sustained hypertension (or occasionally paroxysmal), tachycardia, palpitations, tremor, sweating, flushing, hyperglycemia (secondary to α-stimulated inhibition of insulin secretion)
  • Cerebral vascular accidents and myocardial infarction are possible
  • In patients with chest pain and dyspnea, catecholamine-induced cardiomyopathy should be ruled out. The cardiomyopathy may be reversible if the catecholamine stimulation is removed early before fibrosis has occurred
  • Diagnosis: elevated plasma levels of free catecholamines and elevated urinary vanillylmandelic acid (VMA) levels along with CT findings
  • MIBG (methyl-iodo-benzyl-guanidine) scan may be needed to locate tumor(s)

  • Evaluate for signs of end-organ damage and optimize medical treatment to minimize risk
  • Continue α-adrenergic blockade for at least 10 to 14 days before surgery
    • Both noncompetitive blockers (phenoxybenzamine) and selective α1 blockers (prazosin) have been shown to be equally effective in controlling blood pressure
  • Continue beta blocker therapy (usually used in patients with persistent tachycardia or dysrhythmias), but only with concurrent alpha blockade to avoid unopposed α-mediated vasoconstriction
  • Optimization of medical management indicated by the following:
    • No in-hospital blood pressure higher than 165/90 for 48 hours before surgery
    • Presence of orthostatic hypotension but blood pressure on standing no lower than 80/45 (and typically stuffy nose because of vasodilation)
    • ECG free of ST-T changes
    • No more than one premature ventricular contraction present every 5 minutes
  • Preoperative workup should include
    • TTE to evaluate LV function and relaxation
    • Labs: Na, K, and glucose
  • Normalization of intravascular volume and return of hematocrit toward normal is also recommended
  • Have in room
    • Phentolamine (Bolus: 2–5 mg, Infusion: 1–30 mcg/kg/min)
    • Lidocaine (Bolus: 100 mg, usual concentration 20 mg/mL)
    • Amiodarone (Give 150 mg slowly over 10 minutes, usual concentration 50 mg/mL)

|Download (.pdf)|Print
Brief List of Drugs to Prepare Besides Usual GA Setup
MedicationDilutionInfusion range
Nitroprusside50 mg in 250 mL = 200 mcg/mL0.5–10 mcg/kg/min
Nitroglycerin50 mg in 250 mL = 200 mcg/mL0.5–10 mcg/kg/min
Nicardipine25 mg in 250 mL = 100mcg/mL
  • Start at 5mg/h
  • Increase as needed by 2.5 mg/h increments up to 15 mg/h
Esmolol2.5 g in 250 mL = 10 mcg/mL5–200 mcg/kg/min
Phenylephrine20 mg in 250 mL = 80 mcg/mL0.2–1 mcg/kg/min
Norepinephrine4 mg in 250 mL = 16 mcg/mL0.2–20 mcg/min

  • Pre-induction arterial line
  • Central venous line TLC ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close