Management of undiagnosed pheochromocytoma with acute appendicitis

Letter to editor:Pheochromocytoma is a rare catecholamine-secreting tumor. A proportion of patients are diagnosed at the time of incidental surgery, when induction of anaesthesia may precipitate an hypertensive crisis. In this situation, mortality is close to 80% [1]. The authors report a case of an undiagnosed pheochromocytoma patient with an acute appendicitis.A 17 years old man was scheduled for acute appendicitis. The patient's cardiovascular examination was normal, arterial blood pressure was 135/65 mmHg and heart rate was 85 beats/min. A crush-induction (Propofol 3 m/kg, célocurine 1 mg/kg) was used. Anaesthesia was maintained with sevoflurane in a mixture of nitrous oxide and oxygen. Five minutes after resection the appendicitis, just as washing the abdominal cavity, the blood arterial pressure abruptly increased up to 210/110 mmHg and heart rate increased to 200 beats/min. Anaesthesia was deepened. Medication errors were ruled. There was no skeletal muscle rigidity and the body temperature was 37°c. EtCO2 and airway pressure had not changed and kaliemia was 4.5 mmol/L. An arterial catheter was placed to be able to rapidly detect and treat any hypertension crisis. The arterial pressure continued to rise to 220/120. Heart rate varied from 100 to 140 beats/min. The diagnosis of pheochromocytoma was suspected. The anaesthesiologist and surgeon decided to interrupt the surgery. IV incremental dose of nicardipine and esmolol were given and resulted in arterial pressure of 125/50 mmHg and heart rate of 70 beats/min. Once the patient stabilized, closing the fascia and the skin was effected. Infusion of nicardipine was started and adjusted according to the blood pressure. In intensive care unit, aggressive therapy included nicardipine, propanolol and hydration was continued. After extubation the pression was stabilized by nicardipine 6 mg per hour and propanolol 40 mg twice per day. Abdominal injected computerized tomography showed a unilateral suprarenal mass. Measu