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Hypertensive Krisen endokriner Ursache am Beispiel des Phäochromozytoms

Management of hypertensive emergency in pheochromocytoma

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Intensivmedizin + Notfallmedizin

Summary

Knowledge of the broad spectrum of clinical signs and symptoms associated with pheochromocytoma is a pre-requisite for diagnosis and the avoidance of a wrongly added beta-blocker medication prior to sufficient alpha-blockade. The diagnosis is made biochemically by measuring urine catecholamines and metanephrines. After the pheochromozytoma has been localized, the appropriate preoperative pharmacological therapy is crucial for the prevention of serious vascular complications. With respect to preoperative treatment, an initial alpha-blockade by the non-specific, non-competitive and irreversible alpha-blocker phenoxybenzamine is highly recommended. After a stepwise elevation of phenoxybenzamine up to an individual and maximal tolerable dose, a non-cardioselective betablocker should be added. With strict obedience of these guidelines and since monitoring and anesthesiological procedures have been improved continuously, the incidence of perioperative morbidity and mortality could be reduced dramatically. With respect to emergency therapy, phentolamine is the medication of choice. Due to a limited availability of phentolamine in most countries, urapidil represents a reasonable alternative. If sodium nitroprusside is used, extensive pharmacological and toxicological effects have to be considered.

Zusammenfassung

Die Kenntnis des Spektrums der Symptomatologie des Phäochromozytoms und der Phäochromozytomkrise sind unabdingbare Voraussetzungen für das Erkennen der Erkrankung, der Vermeidung einer kontraindizierten und deletären Betablocker-Applikation ohne initiale Alpha-Blockade sowie der Bahnung der richtigen Diagnostik. Die biochemische Sicherung der Verdachtsdiagnose erfolgt heute unkompliziert über die Bestimmung der Katecholamine und der Metanephrine im 24h-Sammelurin. Nach erfolgter Lokalisationsdiagnostik ist die präoperative pharmakologische Therapie entscheidend für die Vermeidung von Komplikationen und Endorganschäden. Für die präoperative Therapie wird eine initiale Alpha-Blockade mittels des nicht-spezifischen, nicht-kompetitiven, irreversiblen α-Rezeptorantagonisten Phenoxybenzamin dringend empfohlen. Nach einer maximal möglichen Auftitrierung bis zur Normotonie und bis zum Auftreten orthostatischer Beschwerden folgt die Applikation eines nicht-kardioselektiven Beta-Blockers, z. B. Propranolol. Durch konsequente Befolgung dieser Richtlinien sowie durch verbessertes Monitoring und Fortschritte in der Anästhesie konnten die perioperativen Komplikationen deutlich gesenkt werden. Hinsichtlich der Notfalltherapie der hypertensiven Krise beim Phäochromozytom wäre Phentolamin prinzipiell das Mittel der Wahl. Aufgrund schwieriger Verfügbarkeit (importierbar über die Auslands-Apotheke) ist hier Urapidil eine gute Alternative. Beim Gebrauch von Nitroprussid-Natrium sind komplexere pharmakologische und toxikologische Effekte zu beachten.

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  1. Klinik und Poliklinik für Innere Medizin I, Universität Regensburg, 93042, Regensburg, Germany

    A. Schäffler

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Serie: Die Notfall- und Intensivtherapie bei endokrinen und metabolischen Erkrankungen Herausgegeben von J. Schölmerich und Ulrike Woenckhaus (Regensburg)

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Schäffler, A. Hypertensive Krisen endokriner Ursache am Beispiel des Phäochromozytoms. Intensivmed + Notfallmed 42, 16–26 (2005). https://doi.org/10.1007/s00390-005-0519-7

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