Mitigating the Catecholamine Surges: A Case Series on Intraoperative Anaesthetic Management of Resistant Pheochromocytoma

Anaesthetic management of resistant pheochromocytoma

Abstract

Background and Aims: Surgical excision of pheochromocytoma is associated with exaggerated catecholamine surges that may lead to life-threatening haemodynamic instability. Resistant pheochromocytoma, characterised by intraoperative hypertension despite adequate preoperative preparation, poses additional anaesthetic challenges. We present our institutional experience in managing such patients.

 Methods: We retrospectively analysed 20 patients who underwent adrenalectomy for pheochromocytoma at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, from October 2023 to March 2025. Among them, 6 patients developed resistant hypertension intraoperatively. Details of anaesthetic technique, drug infusions, haemodynamic events, and postoperative outcomes were reviewed.

 Results: All patients were preoperatively optimised with alpha- and beta-blockade. Intraoperatively, all 6 resistant cases required simultaneous infusions of nitroglycerine, esmolol, labetalol, lignocaine, and sodium nitroprusside (0.5–5 µg/kg/min) to control hypertension during tumour manipulation. Two patients developed severe hypotension after tumour ligation requiring aggressive fluid therapy, phenylephrine boluses/infusion, and vasopressin infusion. No patient developed arrhythmias, myocardial ischaemia, or cerebrovascular complications. All were shifted to ICU for elective ventilation and recovered uneventfully.

Conclusion: Resistant pheochromocytoma presents formidable intraoperative challenges. Anticipation, vigilant monitoring, and proactive use of multidrug infusion protocols—including SNP—ensure haemodynamic stability and favourable outcomes.