Abstract
Abstract
Pheochromocytoma is rarely seen under the age of 8 years and the anaesthesia for pheochromocytoma surgery is challenging. We present the perioperative management of a 5-year-old boy with intestinal obstruction and two episodes of cerebral haemorrhage who presented for pheochromocytoma resection and enterolysis. Important issues in the management of this patient included choice of vasoactive agents and anaesthetics, control of blood pressure and intracranial pressure, preioperative fluid management, and monitoring technique. Imbalance of fluid and electrolyte disturbance as well as a potentially inevitable drop in blood pressures after complete excision of tumour further complicate patient care. Knowledge of different medical issues involved in this case and their potential impact on anaesthetic management is paramount for safe perioperative patient care.
Keywords: General anaesthesia, Cerebral haemorrhage, Intraoperative monitoring, Paediatrics, Pheochromocytoma.
Introduction
Characterized by high secretion of catecholamines, pheochromocytoma is a tumour that originates from pheochromocytes in the medullar portion of the adrenal glands. This tumour is very rare in children. Only 5% of all pheochromocytomas have been reported in children and the incidence is very low below the age of 8 years. 1 While surgical excision is the definitive treatment, the anaesthesia management presents a challenge, since usually neither preoperative preparations nor management during general anaesthesia can totally prevent haemodynamic fluctuations during surgical manipulation or after removal of the tumour. 2 In children, cases regarding cerebral haemorrhage caused by pheochromocytoma have been rarely reported so far. No report on pheochromocytoma combined with intestinal obstruction in a child was found in literature. Given the rarity of pheochromocytoma with cerebral haemorrhage and intestinal obstruction in a child, there is no published case on its anaesthetic management. Here, we describe the perioperative management of pheochromocytoma resection and enterolysis in a 5-year-old boy with cerebral haemorrhage and intestinal obstruction. The patient\\\'s guardian, his father, gave written consent for publication of this report. An ethical approval of this case report was obtained from our hospital.
Case Report
A 5-year-old boy presenting with a history of sweating, headaches and polyuria for 4 months was admitted to local hospital in March, 2015. Medical examination revealed tachycardia (173 beats/min), hypertension (215/142 mmHg), haemorrhage of the left frontal lobe, and hypertrophy of the left ventricle (ejection fraction: 61%). Blood pressure (BP) and intracranial pressure (ICP) were controlled by sodium nitroprusside and mannitol. Removal of intracranial haematoma and decompressive craniectomy were performed under general anaesthesia. He was transferred to our hospital\\\'s paediatric ward on 16 April, 2015 since headaches and vomiting worsened. Brain CT showed cerebral haemorrhage of the right temporal lobe (Figure 1-A). Thoracic and abdominal CT showed a 37×38 mm mass in the left adrenal gland (Figure 1-B). Urinary 24 hour vanillylmandelic acid (VMA) was 192.62 mmol (reference range
