Complications
A hypertensive crisis may be precipitated by: drugs that inhibit catecholamine uptake such as tricyclic antidepressants and cocaine; opiates; anesthesia induction; and radiographic contrast media. Possible consequences of a hypertensive crisis include cerebral hemorrhage, cardiac arrhythmias, myocardial infarction, encephalopathy, and heart failure.[87]
Treatment of hypertensive crisis includes immediate alpha blockade with an alpha-1 blocker (e.g., terazosin, doxazosin, or prazosin) or with the nonselective alpha-blocker, phenoxybenzamine.[43]
Intravenous agents (nitroprusside, phentolamine, or nicardipine) are short-acting and titratable, and can be used first line.[64] Nitroprusside, phentolamine, or nicardipine can be added, as required, to an oral alpha-1 blocker prescribed in the initial management of hypertensive crisis.[43]
A pheochromocytoma-induced hypertensive crisis may precipitate hypertensive encephalopathy, which is characterized by focal neurologic signs and symptoms, altered mental status, and seizure activity. An intracerebral hemorrhage can occur secondary to a hypertensive crisis. Cerebrovascular accidents secondary to ischemic and embolic phenomena have also been described.
Postoperative hypotension may be avoided by adequate intravenous fluid replacement preoperatively. If occurring, it should be managed with intravascular volume expansion with blood or plasma expanders. Inotropes may be occasionally required and use of vasopressin necessary in the setting of catecholamine-resistant hypotension following pheochromocytoma excision.[99]
Postoperative arrhythmias should be treated with lidocaine or esmolol.
In a case series, postoperative hypoglycemia was seen in 13% of 45 patients resulting from rebound hyperinsulinemia after pheochromocytoma removal, requiring intravenous glucose replacement.[75]
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