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• W2015643457 abstract "Phaeochromocytomas are catacholamine secreting tumours of chromaffin cells. Around 15% are extra-adrenal, and up to 40% of these may be malignant [1]. There are many case reports of different anaesthetic techniques [2, 3], but we have not found any describing a technique suitable for developing countries. We would like to describe a case of presumed phaeochromocytoma presenting for surgery in Tanzania. A young 60-kg woman presented with blurred vision. On examination she had grade IV fundoscopic changes with hypertension. Ultrasound showed a right supra-renal mass, 55 × 54 mm, with normal kidneys, liver and spleen. She had left ventricular hypertrophy and inferior ischaemic changes on her ECG. A presumptive diagnosis of phaeochromocytoma was made, but neither urine vanillylmandelic acid nor blood catecholamine levels were available. She was pregnant at the time of diagnosis and surgery was therefore postponed. The patient miscarried at 8 weeks' gestation. She re-presented 5 months later with abdominal pain and vomiting, with a blood pressure of 180/130. She received nifedipine and captopril before being referred to the urologists for surgery. One unit of blood was donated for autologous transfusion peri-operatively. There are problems with the supply chain for many drugs in developing countries. Phenoxybenzamine was obtained, which she received for one week pre-operatively in a dose of 10 mg tds. The day before surgery, propranolol 20 mg tds was added and oral fluid intake encouraged. Pethidine 75 mg and diazepam 10 mg IM were given 1 h pre-operatively. Monitoring consisted of ECG, non-invasive blood pressure (set to take once every 2.5 min, but able to check continuously), pulse oximetry and a pre-cordial stethoscope. Anaesthesia was induced with lignocaine 60 mg, propofol 150 mg and pancuronium 4 mg. The lungs were hand ventilated with isoflurane 2% in 100% O2 for 3 min before intubation, which was uneventful. Maintenance was with isoflurane 1–2% in 100% O2. Drugs available to control hypertension consisted of hydralazine, pethidine, labetolol, and isoflurane; with adrenaline and ephedrine for hypotension. Intra-operatviely the patient was tachycardic at a rate of around 120 beat.min−1, and there were three major periods of hypertension during tumour manipulation. These were immediately and effectively controlled with a combination of increased isoflurane, 30-mg propofol boluses, and 25-mg pethidine boluses. Unfortunately, during the six months since diagnosis the tumour had spread and was found to be adherent to the inferior vena cava and the sympathetic chain. It was deemed inoperable, a biopsy was taken and surgery terminated. The patient was taken to Intensive Care intubated but breathing spontaneously on a T-piece. She was extubated the following morning and continued to improve until discharge 18 days later. Most case reports of phaeochromocytoma involve invasive arterial pressure, central venous pressure and often cardiac output monitoring. These are not available in many hospitals in the developing world. Capnography and gas analysis were also unavailable. Setting a non-invasive blood pressure machine to ‘continuous’ mode produced a reading approximately every 30 s. A pre-cordial stethoscope and a finger on the pulse allowed the quality of the heart beat to be assessed, giving some indication as to the adequacy of filling. Some drugs are not available – either because they have to be bought individually by the patient, or, as in this case, because two of the drugs (hydralazine and phenoxybenzamine) had to be purchased from a distant town. However, with careful planning, alternatives may be found. Finally, it is often difficult to obtain up to date information on the best techniques for anaesthesia. We are grateful for ‘Anaesthesia 3’ resource CDs, obtainable through TALC (http://www.talcuk.org) and sponsored by the Association of Anaesthetists of Great Britatin and Ireland which contain not only tutorials, but also back copies of Anaesthesia for our reference." @default.
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• W2015643457 date "2009-07-01" @default.
• W2015643457 modified "2023-09-26" @default.
• W2015643457 title "Phaeochromocytoma in a developing country" @default.
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• W2015643457 doi "https://doi.org/10.1111/j.1365-2044.2009.05980.x" @default.
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