An undiagnosed case

of Paraganglioma: A
nightmare for the
Anesthesiologist
Presenters: Dr Amit Sabharwal
Authors: Dr Amit Kohli, Dr Sanjay Nihlani, Dr
Prashanth, Dr Sunil Thakur, Dr Sonia Wadhawan,
Dr Poonam Bhadoria
Maulana Azad Medical College and
associated LN Hospital, New Delhi.

Patient Profile
A

75 yr old male,ASA-1, with an intraabdominal swelling provisionally diagnosed

as retroperitoneal tumor was posted for
laprotomy under GA
Pain abdomen- 2-3 months, Mass
abdomen- 4 to 5 yrs
U/S: large retroperitoneal solid cystic
mass 16x9.6x10.4 cm in dimensions
CECT: large heterogeneously enhancing
solid cystic mass with multiple enhancing
septe
Diagnosis: ??retroperitoneal
mesothelioma, histopath correlation

Pre Anaesthetic
Evaluation
No significant past history- no h/o of any

ailment, previous operation,drug intake, &

palpitations/chest pain ,family history
O/E
BP 124/80, Pulse 64/min, R/R 16bpm, Pallor
present.
Cardiac , GI, Renal & Pul System NAD
Inv included Xray chest, ECG, Hemogram,
KFT, SE, & LFT , Urine R,M were all WNL
except Hb which was 9 gm%
Optimization: 1 unit packed cell transfused
Plan: General anesthesia with epidural
analgesia

Perioperative Events
Standard anesthesia protocol:
On manipulation of mass
Vitals, Ecg changes
Inj Xylocard, Inj propofol
Vent Bigeminy
repeat dose of Inj Xylocard
Vent Tachycardia,Palpable
pulses,hypertension
manipulation stopped,inj amiadarone
bolus,infusion
NTG infusion
vitals under control
Sx continued ,mass resected!

Perioperative Events
Sudden hypotension
Fluid resuscitation
Stable hemodynamics
Monitored over 30 min,regular respiration
Extubatiion trial attempted
Shifted to ICU
Uneventful postoperative period
Epidural

care
Histopathological report- paraganglioma
with concurrent tuberculosis!

Differential Diagnosis
?Intraoperative hypertension..
?Hypertensive episode precipitating an
arythymia
?Undiagnosed catecholamine secreting
tumour
Intraoperative events in retrospect
point to the mass being a silent
paraganglioma.
Though Clinical suspicion is primal in
aiding diagnosis, lack of any signs and
symptoms preoperatively caught us off
guard
Retroperitoneum, a common site
of occurrence for paragangliomas.

Pheochromocytoma,paragan
gliomas

tumors arising from catecholamine producing

chromaffin cells (adrenal /extra adrenal).
Not under neurogenic control
Account for less than 0.1% of all cases of
hypertension in adults.
Eitiology: isolated (90%), inherited
(10%),both sexes of any age affected
10% can turn malignant - liver,bone,spinal
cord,lungs,brain and lymph nodes.
Most tumors secrete NE either alone or more
commonly combined with a smaller amount
of EP (85:15). 15% secrete EP alone.

Topographic
sites

Signs and symptoms

Catecholamin
e pathway
and sites of
action of
various drugs

Preoperative management
Detailed

history,physical
examination,laboratory and cardiac
evaluation.
Optimization with pharmacological agents
Preoperative blood pressure goals: no
standard guidelines: 130/80 mm Hg (while
sitting),100 mm Hg systolic (while
standing, not less than 80/45 mm Hg)
Heart rate: 60-70/min while sitting, 7080/min while standing
Ref: Preoperative management of the
pheochromocytoma patient. Karel Pacak. J Clin
Endocrinol Metab. Nov 2007,92(11):4069-4079

Drugs used:

Alpha

adrenoceptor
antagonists:
phenoxybenzamine,prazosi
n,terazosin,doxazocin
Beta adrenoceptor
antagonists: atenolol,
metoprolol, propranolol
Combined alpha and beta
receptor blockers:
labetalol,carvedilol
Calcium channel blockers:
amlodipine, nicardipine,
nifedipine,varapamil
Catecholamine synthesis
inhibitors

Intraoperative management
Concerns

during induction, intubation, surgical

incision, abdominal exploration, manipulation,
vein ligation,reversal.
Monitoring- noninvasive and invasive
Avoid morphine, atracurium, atropine,
pancuronium, succinylcholine
Safethiopentone,etomidate,benzodiazepines,fentany
l,
sufentanil,alfentanil,enflurane,isoflurane,nitrous
oxide,vecuronium and rocuronium

 Drugs

useful prior to ligation

SNP,phentolamine,niroglycerin,labetalol,magnesiu
m
sulphate,lidocaine,esmolol,amiadarone,diltiazem
Hypotension-most common cause of death(intra
and post op) fluids,depth of anesthesia,
vasopressors ( phenylephrine, norepinephrine)
,inotropes (dopamine)
Post operative:
Vasopressor support
Steroid supplementation
Hypoglycemia
Ventilatory support