Physical Sciences, Engineering and Technology, Biochemistry, Genetics and Molecular Biology, Pharmacology, Toxicology and Pharmaceutical Science, McGill University Health Centre, Montreal, Canada. Labetalol is an alpha- and beta-blocker widely used in the treatment of hypertensive emergencies. Intravenous nitroglycerin may also be administered if needed (8). By Rodrigo Valenzuela B. and Alfonso Valenzuela B. Hypertensive crisis was defined as a systolic blood pressure > 200 mmHg or an increase > 30% in baseline systolic blood pressure during the operation. The ePub format is best viewed in the iBooks reader. Urgent adrenalectomy was eventually performed 4 days after hospital admission. EPIDEMIOLOGY Catecholamine-secreting tumors are rare neoplasms, probably occurring in less than 0.2 percent of patients with hypertension [ 1,2 ]. The primary treatment for a pheochromocytoma is surgery to remove the tumor. Ayaz SI, Sharkey CM, Kwiatkowski GM, et al. Pheochromocytoma is a catecholamine-secreting tumor derived from chromaffin cells. Randomized clinical trials are needed to investigate initial and long-term mortality outcomes in patients with hypertensive emergencies treated with different antihypertensive drugs. Ann Transl Med. Hypertension from pheochromocytoma catecholamine secretion is potentially fatal and requires immediate treatment with cardiac afterload reduction and preload augmentation for end-organ protection. pheochromocytoma is the hypertensive crisis due to the tumoral secretion of catecholamines (1). Intravenous therapy for hypertensive emergencies, part 2. Beta-adrenergic blockade should be added 2–3 days preoperatively after the In 104 patients with a hypertensive emergency with renal dysfunction treated in an emergency department with intravenous nicardipine or labetalol, within 30 min of administration, the target systolic blood pressure was reached in 92% of patients treated with intravenous nicardipine versus 78% of patients treated with intravenous labetalol (9). Papadopoulos DP, Sanidas EA, Viniou NA, et al. Login to your personal dashboard for more detailed statistics on your publications. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. We encountered several case reports of hypertensive crises under general anesthesia in the literature.,, However, to our knowledge, there is only one other case report of a hypertensive crisis under spinal anesthesia related to pheochromocytoma, where the patient became acutely hypertensive during bladder tumor manipulation. The drugs of choice in treating a hypertensive emergency with acute pulmonary edema are intravenous nitroglycerin, clevidipine, or nitroprusside (1,2,5). Certain foods, such as aged cheeses, beer, wine, meats, fish, bananas and chocolate, especially those containing tyramine, have been reported to induce PMC [2]. Conflicts of Interest: The author has no conflicts of interest to declare. One patient’s hypertensive crisis was successfully controlled prior to operative intervention, however, upon development of a fever of 40°C, a septic workup was initiated and the patient became encephalopathic, leading to respiratory distress and had fatal cardiac arrhythmias while awaiting surgery. Patients with pheochromocytoma crisis were analyzed separately from the patients without pheochromocytoma crisis. Pheochromocytoma Treatment . The case reports above describe the clinical presentation of PMC in detail, but there is very limited data regarding the perioperative management of PMC and whether it is preferable to proceed with emergency surgery with preoperative α‐blockade versus medical management alone in the immediate period of crisis, followed by hospital discharge and elective adrenalectomy. However, retrospective study of a larger sample of patients presenting with pheochromocytoma crisis suggests that medical management in the acute setting is appropriate and safe. Pheochromocytomas are rare tumours of the adrenal gland that secrete catecholamines. The maximum initial dose of intravenous hydralazine administered by slow intravenous infusion is 20 mg. Right‐sided adrenal tumours are more common and have a higher preponderance to cause paroxysmal hypertension compared to left‐sided tumours that are generally associated with persistent hypertension. The first‐line agents are α‐adrenergic blockers, the most common of which is phenoxybenzamine, which is a non‐selective blocker with a long half‐life. How? You may notice problems with 7 Patients with pheochromocytoma crisis may present with clinical features of profound sweating, marked tachycardia, pallor, numbness, tingling, and coldness of hands and feet. This dose can be repeated every 4 to 6 h if needed. The incidence is approximately 0.6 cases … Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. This chapter will focus on the medical and surgical management of potentially life‐threatening pheochromocytoma crisis. Medical management of pheochromocytoma is necessary prior to surgical resection. Intravenous enalaprilat may be administered to patients with a hypertensive emergency associated with a high plasma renin state (5,6,12). The combined data for patients undergoing elective and urgent surgery were compared to the emergency surgery group. Pheochromocytoma crisis was defined as severe hypertension or hypotension resulting in end organ damage (cardiovascular decompensation, MI, PE, ARDS, CVA, renal failure, or liver failure). The gold standard of treatment for pheochromocytoma is elective surgical resection after an appropriate, usually 1–2 weeks, course of anti‐hypertensive therapy. The tendency for emergency adrenalectomy was based on anecdotal evidence from published case reports suggesting that medical management alone led to poorer outcomes. Ideally, adrenalectomy should be planned within 4–6 weeks following discharge. Randomized clinical trial data are also needed to determine how fast or how much the blood pressure should be lowered in a hypertensive emergency. . Other mechanisms have been postulated to explain these changes in blood pressure. What causes adrenal pheochromocytoma? An in‐depth review of the clinical presentation, pathophysiology, causes and treatments of pheochromocytoma crisis will be provided, including the controversial areas surrounding decision‐making and timing for adrenalectomy. HeadquartersIntechOpen Limited5 Princes Gate Court,London, SW7 2QJ,UNITED KINGDOM. This chapter will address the clinical presentation of PMC, pathophysiology of pheochromocytoma, causes of PMC and a description of medical versus surgical treatment. Management of pheochromocytoma Surgical resection of the tumor is the treatment of choice and usually cures the hypertension. Adrenalectomy was performed at least 1 month after initial presentation, following medical stabilization and maintenance. Classic presentation of pheochromocytoma consists of a triad of symptoms, including headaches, diaphoresis and palpitations. Surgical resection of the tumor is the treatment of choice for pheochromocytoma and usually results in cure of the hypertension. The gold standard of treatment for pheochromocytoma is elective surgical resection after an appropriate, usually 1–2 weeks, course of anti‐hypertensive therapy. rolling over in bed, Anaesthetic agents: Intravenous, e.g. The drugs of choice in treating patients with a hypertensive crisis and eclampsia or pre-eclampsia are hydralazine, labetalol, and nicardipine (5,6). If BP is not controlled, phenoxybenzamine can be administered by infusion (0.5 mg/kg/daily). In 1980, one group recommended that only brief attempts should be made to stabilize the patient’s haemodynamic and that ‘procrastination’ prior to operative intervention would lead to ‘irreversible shock, renal failure and death’ [12]. - Treatment of a hypertensive crisis due to pheochromocytoma should be based on administration of phentolamine. Pheochromocytoma is a relatively rare tumor of the adrenal glands or of similarly specialized cells outside of the adrenal glands. Evaluation and treatment of hypertensive crises in children. These persons need intensification of their antihypertensive drug therapy. Norepinephrine acts on α‐1‐adrenergic receptors that are located on smooth muscle cells within peripheral arteries and veins, causing vasoconstriction; α‐2‐adrenergic receptors, located on the presynaptic surface of sympathetic ganglia, cause coronary vasoconstriction and peripheral arterial dilatation; and β‐1‐adrenergic receptors located on cardiomyocytes, cause positive inotropic effects, as depicted in Figure 1. There are three treatment options in the case of PMC, including: (1) emergent adrenalectomy, i.e. INTRODUCTION. A hypertensive crisis (systolic BP >250 mmHg) may occur on presentation of a phaeochromocytoma or during surgical resection of the tumour if the patient has not received adequate preoperative medical therapy.
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