scholarly journals MON-194 Phaeochromocytoma-Paraganglioma (PPGL): Post-Operative Hypotension Is a Vanishing Phenomenon

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Esther Osher ◽  
Karen Michele Tordjman ◽  
Joseph Klausner ◽  
Ido Nachmany ◽  
Boaz Sagie ◽  
...  
Keyword(s):  
Tumor Size ◽  
Antihypertensive Drugs ◽  
Systolic Pressure ◽  
Treatment Protocol ◽  
Early Period ◽  
Hemodynamic Instability ◽  
Volume Control ◽  
Adrenal Tumors ◽  
High Sodium ◽  
Catecholamine Levels

Abstract Background: Treatment of hemodynamic instability in patients with PPGL in the intra-and postoperative periods is challenging. Persistent postoperative hypotension is a common and serious complication, reportedly occurring in 30-60% of PPGL patients. This phenomenon reflects 1) high doses of pre-operative antihypertensive drugs; 2) low intravascular volume secondary to chronic catecholamine-induced vasoconstriction with pressure natriuresis; 3) the sudden drop in circulating catecholamines after surgery. It has been shown that tumor size and preoperative levels of catecholamines are directly related to the need for treatment with vasopressor agents in the early period after tumor removal. The aim of this study was to evaluate the efficacy and safety of the current perioperative treatment protocol for PPGL used in our Institute. Methods: We retrospectively reviewed the rate of hemodynamic instability and postoperative hypotension in relation to catecholamine levels, and the efficiency of preoperative pharmacological preparation in consecutive patients with PPGL treated between 2000-2019. Results: There were 39 patients (F/M 19/20; mean age 50.4 ±16.5 years) 33 of which had adrenal lesions and 6 had extra-adrenal tumors. Mean tumor size was 3.9 ±2.2 cm. Median metanephrine and normetanephrine levels were 5 and 10 fold the upper limit of the normal range respectively. All patients were treated with α-blockade (phenoxybenzamine-17, mean dose 60±38 mg/day; doxazosin-22; mean dose 9.6±6.1mg/day) along with β- blockade, and high sodium diet and IV saline 24 hours before the operation. The length of the preoperative preparation period was 3.4±2 weeks. Within the first 24-48 hours from surgery, no episodes of hypotension (<90 mmHg systolic pressure) were recorded. Mean systolic BP was 121 ±14 (range 95-150) with a mean diastolic BP of 70 ±11 (range 89-46). In contrast, intraoperative hypotension occurred in 22% of the patients; and BP surge occurred in 36% of patients, mostly during tumor manipulation. There were no differences between subjects with and without such BP rises/falls in terms of pre/post- surgical BP, catecholamine levels or type of medical treatment. Conclusion: In contrast with older literature and previous reports, the patients in our cohort did not experience postoperative hypotension. This is most likely due to tight BP control while avoiding pre-operative hypotension, and adequate volume control. We propose that proper preoperative management in the modern era can drastically minimize intraoperative hemodynamic instability and post-operative hypotension.

Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma

2018 ◽  
Vol 84 (6) ◽  
pp. 920-923 ◽  
Author(s):  
Nihat Aksakal ◽  
Orhan Agcaoglu ◽  
Nuri Alper Sahbaz ◽  
Ozgur Albuz ◽  
Ayten Saracoglu ◽  
...  
Keyword(s):  
Tumor Size ◽  
Operative Time ◽  
Hypertensive Crisis ◽  
Hemodynamic Instability ◽  
Study Patient ◽  
Tumor Diameter ◽  
Factors Affecting ◽  
Patient Demographics ◽  
Catecholamine Levels

Pheochromocytoma is an uncommon catecholamine-secreting tumor in which resection is often associated with hemodynamic instability (HI). In this study, we aim to clarify the factors affecting surgical HI in patients who underwent surgery with the diagnosis of pheochromocytoma. All patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 and 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. A total of 37 patients were included in this study. Patient demographics, operative time, tumor size, period of medical treatment until surgery, catecholamine levels in urine, and HI patterns were analyzed. There were 23 (62%) male and 14 (38%) female patients. Hemodynamic instability occurred in 13 (35%) patients. Overall, HI was higher in patients with tumor size <6 cm (P < 0.02); moreover, urine catecholamine levels were detected significantly higher than a cutoff value of 2000 mg/24 hours in hemodynamically instable group. In this study, tumor diameter of <6 cm and urine catecholamine levels >2000 mg/24 hours were associated with HI. Preoperative management is essential for preventing hypertensive crisis and HI before or during surgery.

scholarly journals Superior hypertension control with betablockade in the European Sleep Apnea Database

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Svedmyr ◽  
J Hedner ◽  
D Zou ◽  
G Parati ◽  
S Ryan ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Sleep Apnea ◽  
Systolic Blood Pressure ◽  
Research Collaboration ◽  
Antihypertensive Drugs ◽  
Systolic Pressure ◽  
Apnea Hypopnea Index ◽  
Funding Source ◽  
Obstructive Sleep ◽  
Adjusted Model

Abstract Background Arterial hypertension is highly prevalent and frequently difficult to control in patients with obstructive sleep apnea (OSA). High sympathetic activity is a hallmark physiological phenomenon in OSA. We hypothesized that antihypertensive drugs with sympathetic inhibitory properties, in particular beta blockers (BB), may be particularly efficacious in OSA patients. Methods Hypertensive OSA patients receiving blood pressure lowing treatment in the European Sleep Apnea Database (ESADA) were analyzed (n=5818, 69% men, age 58±11 years, body mass index 33±7 kg/m2, apnea hypopnea index 34±26 events/h). Antihypertensive medications (BB, diuretic, renin-angiotensin blocker [RAB], calcium channel blocker [CCB], and centrally acting antihypertensive [CAH]) were classified according to ATC code. Office blood pressure was compared in patients with mono- or combination therapy controlling for confounders. Results Poorly controlled systolic blood pressure according to the ESC/ESH guidelines was found in 66% of patients. Patients receiving monotherapy with RAB, CCB or CAH had 2.2 [95% CI, 1.4–3.0], 3.0 [1.9–4.1] and 3.0 [1.7–4.7] mmHg higher systolic blood pressure compared with those on BB (adjusted model, p=0.007, 0.008 and 0.017, respectively). In those with a combination of two antihypertensive drugs, systolic blood pressure was 3.3 [2.4–4.3], 2.2 [1.3–4.3] and 2.3 [1.4–3.3] mmHg higher in those on CCB/RAB, diuretic/RAB or BB/RAB compared with those on BB/diuretic (adjusted model, p&lt;0.001, 0.019 and 0.001, respectively). Conclusions Uncontrolled blood pressure was common in OSA patients with antihypertensive medication. Patients treated with BB alone or in combination with diuretic was associated with a lower systolic pressure in this large clinical cohort. Funding Acknowledgement Type of funding source: Other. Main funding source(s): European Respiratory Society funded Clinical Research Collaboration (2015-2020)

scholarly journals Laparoscopic transperitoneal adrenalectomy in the large adrenal tumor from single center experience

BMC Surgery ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Thanasit Prakobpon ◽  
Apirak Santi-ngamkun ◽  
Manint Usawachintachit ◽  
Supoj Ratchanon ◽  
Dutsadee Sowanthip ◽  
...  
Keyword(s):  
Tumor Size ◽  
Adrenal Tumor ◽  
Intraoperative Complications ◽  
Perioperative Outcomes ◽  
Adrenal Tumors ◽  
Transfusion Rate ◽  
Intraoperative Complication ◽  
Estimated Blood Loss ◽  
Group 2 ◽  
Laparoscopic Transperitoneal

Abstract Background The role of laparoscopic adrenalectomy (LA) in a large adrenal tumor is controversial due to the risk of malignancy and technical difficulty. In this study, we compared the perioperative outcomes and complications of LA on large (≥ 6 cm) and (< 6 cm) adrenal tumors. Methods We retrospectively reviewed all clinical data of patients who underwent unilateral transperitoneal LA in our institution between April 2000 and June 2019. Patients were classified by tumor size into 2 groups. Patients in group 1 had tumor size < 6 cm (n = 408) and patient in group 2 had tumor size ≥ 6 cm (n = 48). Demographic data, perioperative outcomes, complications, and pathologic reports were compared between groups. Results Patients in group 2 were significant older (p = 0.04), thinner (p = 0.001) and had lower incident of hypertension (p = 0.001), with a significantly higher median operative time (75 vs 120 min), estimated blood loss (20 vs 100 ml), transfusion rate (0 vs 20.8%), conversion rate (0.25 vs 14.6%) and length of postoperative stays ( 4 vs 5.5 days) than in group 2 (all p < 0.001). Group 2 patients also had significantly higher frequency of intraoperative complication (4.7 vs 31.3%; adjust Odds Ratio [OR] = 9.67 (95% CI 4.22–22.17), p-value < 0.001) and postoperative complication (5.4 vs 31.3%; adjust OR = 5.67 (95% CI 2.48–12.97), p-value < 0.001). Only eight (1.8%) major complications occurred in this study. The most common pathology in group 2 patient was pheochromocytoma and metastasis. Conclusions Laparoscopic transperitoneal adrenalectomy in large adrenal tumor ≥ 6 cm is feasible but associated with significantly worse intraoperative complications, postoperative complications, and recovery. However, most of the complications were minor and could be managed conservatively. Careful patient selection with the expert surgeon in adrenal surgery is the key factor for successful laparoscopic surgery in a large adrenal tumor. Trial registration: This study was retrospectively registered in the Thai Clinical Trials Registry on 02/03/2020. The registration number was TCTR20200312004.

scholarly journals Massive Pulmonary Embolism Complicating Coronavirus Disease 2019 (COVID-19) Pneumonia: A Case Report

2020 ◽  
Vol 2020 ◽  
pp. 1-5
Author(s):  
Shruti Hegde ◽  
Gemini Yesodharan ◽  
John Tedrow ◽  
Alena Goldman
Keyword(s):  
Pulmonary Embolism ◽  
Respiratory Failure ◽  
Acute Pulmonary Embolism ◽  
Ventilatory Support ◽  
Systolic Pressure ◽  
Hemodynamic Instability ◽  
Right Heart ◽  
Timely Diagnosis ◽  
Systemic Thrombolytic Therapy ◽  
Clinical Instability

Background. Patients with severe COVID-19 pneumonia are hypercoagulable and are at risk for acute pulmonary embolism. Timely diagnosis is imperative for their prognosis and recovery. This case describes an otherwise healthy 55-year-old man with respiratory failure requiring mechanical ventilatory support secondary to COVID-19 pneumonia. Massive acute pulmonary embolism with right heart failure complicated his course. Case. A healthy 55-year-old man presented to our emergency department (ED) with a sore throat, cough, and myalgia. A nasopharyngeal swab was obtained, and he was discharged for home quarantine. His swab turned positive for SARS-CoV-2 infection on real-time reverse transcriptase-polymerase chain reaction assay (RT-PCR) on day 2 of his ED visit. A week later, he represented with worsening shortness of breath, requiring intubation for hypoxic respiratory failure due to COVID-19 pneumonia. Initially, he was easy to oxygenate, had no hemodynamic compromise, and was afebrile. On day 3, he became febrile and developed significant hemodynamic instability requiring maximum vasopressor support and oxygenation difficulty. His ECG revealed sinus tachycardia with S1Q3T3 pattern. On bedside TTE, there was evidence of right heart strain and elevated pulmonary artery systolic pressure of 45 mmHg. All data was indicative of a massive APE as the etiology for his hemodynamic collapse. A decision was made to forgo computed tomography pulmonary angiography (CTPA), given his clinical instability, and systemic thrombolytic therapy was administered. Within the next 12-24 hours, his hemodynamic status significantly improved. Conclusions. This case highlights the importance of considering massive APE in COVID-19 patients as a cause of the sudden and rapid hemodynamic decline. Furthermore, timely diagnosis can be made to aid in appropriate management with the help of bedside TTE and ECG in cases where CTPA is not feasible secondary to the patient’s hemodynamic instability.

Influence of drugs and gender on the arterial pulse wave and natriuretic peptide secretion in untreated patients with essential hypertension

2002 ◽  
Vol 103 (5) ◽  
pp. 493-499 ◽  
Author(s):  
Alison J. DEARY ◽  
Anne L. SCHUMANN ◽  
Helen MURFET ◽  
Stephen HAYDOCK ◽  
Roger S. FOO ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Natriuretic Peptide ◽  
Pulse Wave ◽  
Antihypertensive Drugs ◽  
Augmentation Index ◽  
Systolic Pressure ◽  
Fold Increase ◽  
Paradoxical Response ◽  
Reflected Wave ◽  
And Gender

Recent studies have suggested a differential influence of mean pressure and pulse pressure on myocardial infarction and stroke, and differences among the major drugs in their efficacy at preventing these individual endpoints. We hypothesized that antihypertensive drugs have differing influences upon the pulse wave even when their effects on blood pressure are the same. We studied 30 untreated hypertensive patients, aged 28—55 years, who were rotated through six 6-week periods of daily treatment with amlodipine 5mg, doxazosin 4mg, lisinopril 10mg, bisoprolol 5mg, bendrofluazide 2.5mg or placebo. The best drug was repeated at the end of the rotation. Blood pressure readings and radial pulse tonometry (by Sphygmocor®) were performed at each visit, and blood was taken for measurement of levels of atrial natriuretic peptide and brain natriuretic peptide (BNP). The Sphygmocor derivation of the central aortic pulse wave was used to measure time for transmission of the reflected wave (TR) and the augmentation index (AI), which is the proportional increase in systolic pressure due to the reflected wave. There was a dissociation between the effects of the drugs on blood pressure and pulse wave analysis. Bisoprolol caused the greatest falls in blood pressure and TR, but was the only drug to increase AI. This paradoxical response to bisoprolol was associated with a 3-fold increase in plasma BNP levels. There was a smaller elevation of BNP in women compared with men, as described previously, and this elevation also was associated with significantly higher values of AI. Other drugs reduced AI, and this was associated with a significant decrease in BNP by amlodipine. In conclusion, antihypertensive drugs differ in their short-term effects on augmentation of the systolic pulse wave and secretion of BNP from the heart, regarded as a sensitive measure of strain on cardiomyocytes. These differences may help to explain cause-specific differences in outcome in recent trials.

Controlled breathing protocols probe human autonomic cardiovascular rhythms

1998 ◽  
Vol 274 (2) ◽  
pp. H709-H718 ◽  
Author(s):  
William H. Cooke ◽  
James F. Cox ◽  
André M. Diedrich ◽  
J. Andrew Taylor ◽  
Larry A. Beightol ◽  
...  
Keyword(s):  
Arterial Pressure ◽  
Transfer Functions ◽  
Spectral Power ◽  
Systolic Pressure ◽  
Low Frequency ◽  
Volume Control ◽  
Fixed Frequency ◽  
Random Frequency ◽  
End Tidal ◽  
Cardiovascular Rhythms

The purpose of this study was to determine how breathing protocols requiring varying degrees of control affect cardiovascular dynamics. We measured inspiratory volume, end-tidal CO2, R-R interval, and arterial pressure spectral power in 10 volunteers who followed the following 5 breathing protocols: 1) uncontrolled breathing for 5 min; 2) stepwise frequency breathing (at 0.3, 0.25, 0.2, 0.15, 0.1, and 0.05 Hz for 2 min each); 3) stepwise frequency breathing as above, but with prescribed tidal volumes; 4) random-frequency breathing (∼0.5–0.05 Hz) for 6 min; and 5) fixed-frequency breathing (0.25 Hz) for 5 min. During stepwise breathing, R-R interval and arterial pressure spectral power increased as breathing frequency decreased. Control of inspired volume reduced R-R interval spectral power during 0.1 Hz breathing ( P < 0.05). Stepwise and random-breathing protocols yielded comparable coherence and transfer functions between respiration and R-R intervals and systolic pressure and R-R intervals. Random- and fixed-frequency breathing reduced end-tidal CO2modestly ( P < 0.05). Our data suggest that stringent tidal volume control attenuates low-frequency R-R interval oscillations and that fixed- and random-rate breathing may decrease CO2 chemoreceptor stimulation. We conclude that autonomic rhythms measured during different breathing protocols have much in common but that a stepwise protocol without stringent control of inspired volume may allow for the most efficient assessment of short-term respiratory-mediated autonomic oscillations.

scholarly journals Comparison of Adrenal Tumor Size in Ultrasound Examinations with and without the Use of a Contrast Agent

Medicina ◽  
2019 ◽  
Vol 55 (5) ◽  
pp. 165
Author(s):  
Mateusz Winder ◽  
Wojciech Spychałowicz ◽  
Aleksander Owczarek ◽  
Jerzy Chudek
Keyword(s):  
Tumor Size ◽  
Adrenal Tumor ◽  
Three Dimensional ◽  
Adrenal Tumors ◽  
Tumor Vascularization ◽  
Mri Scan ◽  
Contrast Enhanced ◽  
Median Volume ◽  
Doppler Techniques ◽  
Adrenal Volume

Background and objectives: Patients diagnosed with incidentally found adrenal tumors (incidentaloma) that do not meet the criteria for surgical treatment require follow-ups with repeated imaging. The aim of this study is to compare the accuracy of the measurements of the adrenal tumor size in ultrasound (US) with and without contrast in comparison to computed tomography (CT) or magnetic resonance (MRI). Further, this study attempts to answer the question of whether contrast-enhanced ultrasound (CEUS) can improve imaging accuracy and replace CT/MRI in the monitoring of patients with adrenal tumors. Materials and Methods: The retrospective analysis included 79 adult patients with adrenal incidentalomas not exceeding a dimension of 6 cm who underwent a CT or MRI scan, US, and CEUS with the use of SonoVue in two-dimensional (2D) and three-dimensional (3D) projections and Doppler techniques. Tumor vascularization in CEUS was classified as follows: peripheral, peripheral-central, central, or poor. Results: Of 79 adrenal tumors, 48.1% showed peripheral, 29.1% showed poor, 21.5% showed peripheral-central, and only 1.3% showed central vascularization. The median volume of tumors detected with CEUS (69.9 cm3) was significantly higher than with US (44.5 cm3) and CT or MRI (57.1 cm3). The relative error of the adrenal volume with CEUS compared with CT or MRI was significantly higher than with standard US, regardless of the type of tumor vascularization. Conclusions: CEUS does not improve the accuracy of adrenal tumor size assessment regardless of the type of vascularization.

scholarly journals Laparoscopic Adrenalectomy for Potentially Malignant Adrenal Tumors Greater than 5 Centimeters

2006 ◽  
Vol 91 (8) ◽  
pp. 3080-3083 ◽  
Author(s):  
Chun-Hou Liao ◽  
Shih-Chieh Chueh ◽  
Ming-Kuen Lai ◽  
Po-Jen Hsiao ◽  
Jun Chen
Keyword(s):  
Tumor Size ◽  
Laparoscopic Adrenalectomy ◽  
Malignant Tumors ◽  
Adrenal Tumors ◽  
Benign Tumors ◽  
Conversion To Open Surgery ◽  
Open Conversion ◽  
Potentially Malignant ◽  
Adrenocortical Carcinomas

Abstract Purpose: Laparoscopic adrenalectomy (LA) is controversial for large, potentially malignant tumors. We report a series of LA or hand-assisted LA for large (&gt;5 cm) adrenal tumors. Patients and Methods: Among 210 LAs performed in 6 yr, 39 patients had potentially malignant tumors greater than 5 cm in diameter. Their perioperative and follow-up data were retrospectively analyzed. Results: All 39 patients had successful LAs without perioperative mortality, conversion to open surgery, or capsular disruption during dissection. The mean tumor size was 6.2 cm (range, 5–12 cm), operative time 207 min (115–315 min), and blood loss 75 ml (minimal–1400 ml). Complications included one intraoperative diaphragmatic perforation, three mild wound infections, and one pneumonia. Preoperatively there were 27 nonfunctioning tumors, seven pheochromocytomas, three cortisol-secreting tumors, and two virilizing tumors. Final pathology revealed eight malignant (four adrenocortical carcinomas and four metastatic carcinomas) and 31 benign tumors (14 cortical adenomas, eight pheochromocytomas, six myelolipomas, and three ganglioneuromas). Median follow-up was 39 months. Four patients (two adrenocortical carcinomas, one metastatic hepatoma, and one lymphoma) died 24, 10, 9, and 3 months after surgery, respectively. A hand-assisted device was used in 10 patients. Only the tumor size was larger and length of postoperative hospital stay longer for those in the hand-assisted group. Conclusions: LA is a reasonable option for selected large adrenal tumors when complete resection is technically feasible and there is no evidence of local invasion. Hand-assisted LA is a good alternative to open conversion if a difficult dissection is encountered intraoperatively.

scholarly journals Functional and non-functional types of adrenal tumors: a case series

F1000Research ◽  
2021 ◽  
Vol 10 ◽  
pp. 675
Author(s):  
Dwiki Haryo Indrawan ◽  
Fauriski Febrian Prapiska ◽  
Syah Mirsya Warli ◽  
Bungaran Sihombing ◽  
Ginanda Putra Siregar
Keyword(s):  
Blood Pressure ◽  
Adrenal Tumor ◽  
Antihypertensive Drugs ◽  
Histopathological Examination ◽  
Left Kidney ◽  
Case Series ◽  
Neural Crest Cell ◽  
Adrenal Tumors ◽  
The Third ◽  
Adrenal Cortical Adenoma

Adrenal gland masses could be classified into functional, malignant, or benign. An adrenal cortical adenoma is one of the most common incidentalomas found with either functional or non-functional type. Pheochromocytoma is a neural crest cell origin tumor associated with catecholamine production. A classic triad of headache, sudden episodic perspiration, and tachycardia marked a pheochromocytoma. We report three patients with adrenal tumors. First, a 52-year-old woman with complaints of pain in the left flank suggests a left kidney tumor. The patient has an increased blood pressure intraoperatively. Adrenal cortical adenoma was found postoperatively. The second case is an Indonesian male 27-year-old with pain in the upper right abdomen. Intraoperative, the patient also has an escalation in blood pressure. Antihypertensive drugs are also used in this patient. Postoperatively, a pathology result of pheochromocytoma was revealed from this patient. The third case, adrenal myelolipoma, was suspected in a 48-year-old male and underwent surgery because of tumor growth. Later, a histopathological examination revealed myelolipoma of the adrenal. Management of adrenal tumor should be done individually based on each patient. In the first and second cases, blood pressure was unstable intraoperatively and was managed using several drugs, and was stable at follow-up. In the third case was no hemodynamic problem. In the case of an adrenal tumor, management tailoring should be based on the individual patient.

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