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Anaesthesia, 1986, Volume 41, pages 1225-1229

CASE REPORT

Vecuronium and phaeochromocytorna


A report of two cases using different modes of administration

M . J . D A R O W S K I , W . B. A . C O U T I N H O , S . J . P O W E R AND R. M . JONES

Summary
Two patients presenting for removal of phaeochromocytoma are described. Vecuronium was used to provide
neurornuscular blockade by two different methods of administration: an infusion and a large bolus dose.
Both gave satisfactory results and we suggest that vecuroniurn may be the neuromuscular blocking agent
of choice for patients uith phaeochromocytoma.

Key words
Neurornuscular relaxants; vecuronium.
Surgery; phaeochromocytoma.

Vecuronium has been shown t o be remarkably and marked cardiac dysrhythmias during anaes-
cardiostable’ - 4 and to cause minimal histamine thesia on that occasion. The acute episode was
release.’ These properties suggest that it may be treated with intravenous practolol and he was
the muscle relaxant of choice for patients with discharged to the care of his general practitioner
phaeochromocytoma.6 We report the details of who treated his hypertension with a /3-adrenergic
two patients in whom vecuronium was admin- antagonist which was later changed t o spiro-
istered by different modes in order to achieve nolactone.
muscle relaxation during anaesthesia for phaeo- Earlier in the year he presented again for minor
chromocytoma removal. surgery t o a toe. His arterial blood pressure was
180/120 mmHg. He was premedicated with
papaveretum 15 mg and hyoscine 0.3 mg one
Case histories hour pre-operatively and was noted to be anxious
on arrival in the anaesthetic room. Anaesthesia
Case 1
was induced with thiopentone; he then developed
A 37-year-old male weighing 69 kg presented for severe hypertension (systolic arterial pressure
removal of phaeochromocytorna. He had a 2-year 200 mmHg) and a tachycardia of 140 beats/
history of hypertension which had been minute. This eventually responded to an infusion
diagnosed during an admission to hospital for a of sodium nitroprusside and a bolus of practolol.
nasal operation. He had a hypertensive reaction A preliminary diagnosis of phaeochromocytoma

M.J. Darowski. MB. ChB, FFARCS. Senior Registrar, Department of Anaesthetics, Guy’s Hospital, St Thomas’s
Street, London SEI 9RT, W.B.A. Coutinho, MB, BS, FFARCSI, FFARCS, Senior Registrar, Department of
Anaesthetics, Greenwich District Hospital, Vanbrugh Hill, London SElO 9HE. S.J. Power, MB, BS, FFARCS,
Lecturer in Anaesthetics. R.M. Jones, MB, ChB, FFARCS, Senior Lecturer in Anaesthetics, The United Medical
and Dental Schools ofGuy’s and St Thomas’s Hospitals (University of London), Guy’s Hospital, London SEI 9RT.

0003-2409/86/121225 + 05 W3.00/0@ 1986 The Association of Anaesthetists of Gt Britain and Ireland 1225
1226 M.J. Darowski et al.
was made and this was confirmed following administration of the vecuronium. There was no
estimation of urinary catecholamine metabolites. increase in either heart rate or arterial blood
He was started on labetolol 100 mg twice daily. pressure in response to either relaxant admini-
A postoperative ECG showed ST elevation and stration, laryngoscopy or tracheal intubation. A
T-wave inversion in leads V2-,. central venous catheter was sited via the right
He was transferred to this hospital for definitive internal jugular vein and the bladder was cath-
treatment. He gave a 2-year history of episodes eterised. Anaesthesia was maintained with
of palpitations, sweating, headaches and anxiety nitrous oxide in 30% oxygen with isoflurane
attacks, which occurred 1-2 times a month and 0.5-1 YO.The patient was gently turned to the
were often brought on by straining at stool. right lateral position and surgery allowed to
Physical examination was normal, apart from proceed. Neither position nor surgical incision
an arterial blood pressure of 170/100 mmHg. produced responses in either heart rate or arter-
Serum and urinary catecholamine levels were ial blood pressure.
markedly raised. A random blood sugar was Dissection and manipulation of the tumour
6.3 mmol/litre (normal range 3.3-5.5 mmol/litre). initiated a rise in arterial blood pressure to a peak
Other blood results were normal. The ECG of 182/117 mmHg which was treated first by
showed evidence of a small anteroseptal infarct increasing the isoflurane concentration to 2%,
with subendocardial extension. This had most then by increments of phentolamine 1 mg to a
probably occurred during his last anaesthetic. total of 7 mg and finally by a brief infusion of
'
Computerised tomography and an I '-labelled sodium nitroprusside. The arterial blood pressure
meta-iodo-benzyl-guanidine (MIBG)' scan settled to a systolic of 100 mmHg over a period
showed a solitary phaeochromocytoma in the of 15 minutes. No dysrhythmias were seen. The
region of the left adrenal. arterial blood pressure decreased rapidly to 80
Adequate control of his blood pressure was mmHg systolic after removal of the tumour and
achieved following 40 days incremental treatment 2 mg methoxamine were administered to return
with phenoxybenzamine 90 mg tds, propranolol it to 100 mmHg. Blood loss was 350 ml. The
60 mg tds and a-methyl-para-tyrosine* 500 mg remainder of the operative course was uneventful
three times a day. When his arterial blood and no further increments of analgesia or muscle
pressure had fallen to 120/8&130/90 mmHg, he relaxant were required.
was prepared for surgery. He was alert and TIhad returned to 20% of control at the end
complained of feeling restless and agitated. of the procedure, one hour and 55 minutes after
He was premedicated with papaveretum 20 mg the injection of vecuronium. Neuromuscular
and hyoscine 0.4 mg one hour pre-operatively blockade was reversed with edrophonium 0.5
and arrived in the anaesthetic room very sedated. mg/kg and glycopyrrolate 0.005 mg/kg. Reversal
ECG leads and an automatic blood pressure cuff was prompt with a return of T , to 50% of control
(Accutor Datascope) were placed and baseline and a Tq ratio of 0.5 within a minute. The
readings obtained. Anaesthesia was induced with isoflurane was switched off and the trachea
nitrous oxide in 30% oxygen and isoflurane up extubated once spontaneous ventilation was
to 2%. An intravenous line and a radial artery established.
cannula were sited and a continuous display of The patient remained very drowsy in the post-
arterial blood pressure obtained. Electrodes for operative period, and was still not fully awake
the neuromuscular transmission monitor (Datex some 12 hours postoperatively, despite a normal
Relaxograph) were placed over the left ulnar blood sugar level.g Large volumes of colloid were
nerve and hypothenar eminence and calibration required to maintain central venous pressure,
and baseline values were obtained. Fentanyl 1.5 arterial blood pressure and urine output in the
pg/kg and vecuronium 28 mg (0.4 mg/kg, EDpl x first 24 hours and the patient required 3 litres of
8) were given into a fast-running infusion. Neuro- plasma and 2 units of blood. He developed a
muscular blockade was monitored by train-of- staphylococcal pneumonia within the first 14
four (TOF) stimulation every 20 seconds. postoperative hours for which he required con-
Ventilation of the lungs was assisted at the trolled ventilation of the lungs for 30 hours. He
onset of paralysis, laryngoscopy performed and responded well to physiotherapy and a course of
the larynx sprayed with 4% lignocaine. The cephazolin and his further postoperative course
trachea was intubated within 90 seconds of was uneventful.
Vecuronium and phaeochromocytoma 1227

Case 2 was controlled to maintain normocarbia (Datex


capnograph). Neuromuscular function was mon-
A 30-year-old female presented for removal of itored by train-of-four every 20 seconds. When
phaeochromocytoma. She was discovered to be twitch height had returned to 10% of control an
hypertensive earlier in the year, when she visited infusion of vecuronium (0.2 mg/ml) was started.*O
her general practitioner to be prescribed the oral The infusion was delivered by a Vickers Treonic
contraceptive pill. Her only complaint was of syringe pump and adjusted to maintain a twitch
occasional episodes of palpitations and in the height between loo/, and 15% of control.
CQUrSe of investigation she was found to have Surgical incision and abdominal exploration
raised levels of vanillylmandelic acid. She had produced a rise in blood pressure to a peak of
had uneventful general anaesthesia in both 1980 200 mmHg systolic. This was treated with incre-
and 1983 and was noted to be normotensive on ments of phentolamine 1 mg (total 5 me). Blood
both occasions. Her general practitioner had pressure settled to control within minutes of
started treating her with nifedipine slow release removal of the tumour. There were no dysrhy-
20 mg twice daily. thmias. Blood loss was approximately 500 ml.
On admission, her arterial blood pressure was The vecuronium infusion was stopped towards
220/120 mmHg. Her physical examination was the end of the procedure and at the end of surgery
otherwise normal. She gave a one-year history of T I had reached 50% of control. Residual
attacks of palpitations. She was taking no neuromuscular blockade was reversed with
medication apart from nifedipine. She had raised neostigmine 2.5 mg and glycopyrrolate 0.5 mg.
urinary and serum catecholamine levels and A T4 ratio of 0.5 was achieved within a minute
mildly raised thyroid function tests. An of reversal. Anaesthesia had lasted for 90 minutes
MIBG scan showed an area of massive uptake and 1.8 mg of the vecuronium infusion had been
above the left kidney. Her ECG showed sinus administered. When spontaneous ventilation was
tachycardia. established, the trachea was extubated and the
Her blood pressure after admission stabilised patient transferred to the intensive care unit
at 110/70 mmHg after 3 weeks treatment with where she made an uneventful recovery.
phenoxybenzamine 30 mg, propranolol 20 mg
and nifedipine 20 mg all twice daily and Lugol's
Discussion
iodine (10 drops/day) for six days.
She was premedicated with lorazepam 2 mg The mortality due to surgery for removal of
otally 2 hours pre-operatively, followed by phaeochromocytoma has declined dramatically
papaveretum 15 mg and hyoscine 0.3 mg an hour over the past three A number of
later. On arrival in the anaesthetic room fentanyl factors have probably contributed to this
100 pg was given by slow intravenous injection d e ~ l i n e , ' ~ .although
'~ the precise role of im-
through an indwelling needle. A radial artery proved anaesthetic technique is difficult to
cannula, an intravenous cannula and a right atrial quantify." There is, however, no doubt that the
cannula via the right internal jugular vein were choice of anaesthetic agent@) can, and does,
all sited under local anaesthesia. Electrodes for influence the incidence of intra-operative
the neuromuscular transmission monitor (Datex complications such as hypertension and dysrhy-
Relaxograph) were placed as described pre- thmia.14*16
viously. Anaesthesia was induced with thiopen- All muscle relaxants, with the possible excep-
tone 250 mg followed by a further 150pgfentanyl. tion of vecuronium, have the potential to cause
Ventilation was assisted by facemask, while cardiovascular side effects which may, or may
calibration and baseline recordings of neuro- not, be associated with histamine release. In
muscular function were obtained. Vecuronium patients with phaeochromocytoma, histamine
5 mg was administered and, after an interval of release is particularly undesirable because it can
2 minutes, the trachea was intubated. There was cause hypertension and indeed, this has been
no rise in heart rate or blood pressure following used as a diagnostic test for the condition."
either induction of anaesthesia, relaxant admin- Vecuronium probably has the least tendency to
istration or intubation of the trachea. Anaesthesia cause histamine release3.' * of all the available
was maintained with nitrous oxide in 33% oxygen relaxants. Suxamethonium is relatively contra-
and isoflurane 0.5-1%. Ventilation of the lungs indicated in patients with phaeochromocytoma,
1228 M.J. Darowski et al.

both because of its autonomic side effectsl9-21 in arterial blood pressure can be attained. In
and also because fasciculations may cause release a sense it may be termed ‘inhalational sodium
of catecholamines from the tumour.l6 Pancuron- nitroprusside’.
ium has little potential to initiate histamine The patient in Case 1 had required treatment
r e l e a ~ e ,but
~ it has been reported to cause with a-methyl-para-tyr~sine***~ to control his
hypertension in a patient with phaeochromocy- hypertension: This is a competitive inhibitor of
toma,” presumably due to its sympathomimetic tyrosine hydroxylase which acts centrally as well
a~tivity.’~.’‘ Similarly, gallamine has sym- as in the periphery. This enzyme is the rate-
pathetic activity which, coupled with a marked limiting step in catecholamine synthesis. In
tachycardia due to vagal blockade, means this patients with phaeochromocytoma, treatment
agent is unsuitable.” reduces daily catecholamine synthesis by 20-80%.
Theoretically, therefore, vecuronium appears Either on its own, or in combination with
to be the agent of choice for patients with phenoxybenzamine it usually produces adequate
phaeochromocytoma and its successful use in this control of blood pressure and of symptoms and
situation has been reported.6 The customary has been used for the treatment of patients with
method of administration by intermittent bolus malignant phaeochromocytoma not amenable to
doses has the disadvantage that it results in surgical
fluctuating levels of muscle relaxation. This may Alpha-methyl-para-tyrosine has two side
be particularly undesirable in patients with effects of anaesthetic importance. First, it can
phaeochromocytoma, in whom coughing and potentiate the extrapyramidal side effects of
straining may cause sudden massive catechola- butyrophenones (e.g. droperidol) and second it
mine may cause sedation, which will potentiate the
Administration by infusion has been suggested effects of other central nervous system depres-
as an answer to this problem and in our report sants. Occasionally, psychic stimulation may
this technique worked satisfactorily. However, occur and our patient was restless and agitated
the use of infusions of muscle relaxant necessitates pre-operatively. It was interesting that he was
the availability of a method of reliable delivery very heavily sedated following premedication,
of the drug and of monitors of effect; without even though similar premedication with his
these, the technique cannot be used. previous anaesthetic had been described as
An alternative is the use of a large bolus dose inadequate. Phenoxybenzamine is also reported
of vecuronium which prolongs its duration of to cause sedation,” so that the precise nature of
action. We administered an ED95 x 8 dose the interaction is difficult to interpret. Whatever
(28 mg) of vecuronium and have demonstrated the cause, it seems likely that his prolonged period
that even this very large bolus did not cause any of peri-operative sedation and hence relative
cardiovascular effects and provided satisfactory immobility was a contributory factor to his
relaxation for the entire procedure. postoperative pulmonary complications.
The use of isoflurane for anaesthesia in patients In summary, we have described two techniques
with phaeochromocytoma has been well docu- for administering vecuronium to patients anaes-
mented.26-Z*Previous authors have commented thetised for removal of phaeochromocytoma.
on the stability of cardiac rhythm during iso- Both were very satisfactory in the cases described
flurane anaesthesia for removal of catecholamine- and the choice of technique may be influenced
secreting turnours. Neither of our patients had by the availability of infusion devices and of
any disturbances of cardiac rhythm, other than methods of monitoring neuromuscular trans-
sinus tachycardia, at any time. This included, in mission. If such devices are not available, we
both patients, the period of tumour manipulation, suggest that the use of a large bolus dose
when the sudden increase in arterial pressure (0.4 mg/kg, EDss x 8) will produce prolonged
(despite adequate pre-operative a- and /I- surgical relaxation. In our patient, even this very
blockade) suggests that circulating catecholamine large dose of vecuronium was without cardio-
levels must have been substantially increased. A vascular side effects. We suggest that whatever
further advantage of isoflurane is that it is a the method of administration, vecuronium is
potent vasodilator, and because of its low probably the muscle relaxant of choice in patients
blood/gas partition coefficient, rapidly reversible presenting for the removal of a phaeochromo-
changes in systemic vascular resistance and thus cytoma.
Vecuronium and phaeochromocytoma 1229

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