Abstract
This report describes the anaesthetic management of a women with a term gestation, Von Hippel Lindau disease (VHLD), and a phaeochromocytoma, scheduled for a combined phaeochromocytoma resection and Caesarean section. Von Hippel Lindau disease is characterized by diffuse haemangioblastomas of the central nervous system (CNS) and viscera. It is also associated with phaeochromocytomas and renal cell carcinomas. Patients frequently have asymptomatic spinal cord and intracranial pathology. The patient and her fetus presented a challenge because of the anaesthetic restrictions imposed by VHLD, and her pregnancy. She was also at risk of developing malignant hypertension from the phaeochromocytoma. The patient was not a candidate for regional anaesthesia because of the possibility of spinal cord haemangioblastomas. She had received adrenergic blockade with phentolamine (total 30 mg a day) and propranolol (total 40 mg a day) since the 27th wk of gestation in order to control hypertension secondary to the phaeochromocytoma. General anaesthesia was administered with aggressive management of hypertension with adrenergic blockers (labetalol 1.0 mg · kg−1 and esmolol 0.75 mg · kg−1) and sodium nitroprusside 1.5 μg · kg−1 (total). Before delivery of the baby, opioids, which could have resulted in a fetus with CNS depression, were avoided. After delivery, opioids (sufentanil 0.4 ng · kg−1 hr−1) were used to limit the use of inhalational anaesthesia which may contribute to uterine atony. Postoperative pain was managed with an intravenous narcotic infusion. Both patients had uneventful postoperative courses.
Résumé
Cette observation décrit la conduite anesthésique chez une parturiente à terme souffrant de la maladie de Von Hippel Lindau (MVHL) associée a un phéochromocytome, programmée pour une césarienne et une résection simultanée de phéochromocytome. La maladie de Von Hippel Lindau est caractérisée par une hémangioblastomatose diffuse du système nerveux central et des viscères. Elle s’accompagne souvent de phéochrocytomes et de cellules carcinomateuses rénales. Les pathologies spinale et intracrânienne sont souvent silencieuses. La MVHL et la grossesse rendent plus complexe la conduite anesthésique. Au phéochromocytome se greffe aussi un risque d’hypertension maligne. La possibility d’hémangioblastose spinale fait de la malade une mauvaise candidate pour la régionale. A partir de la 27ième semaine de gestation, l’hypertension secondaire au phéochromocytome est contrôlée par une médication antiadrénergique de phentolamine (30 mg par jour) et de propanolol (40 mg par jour). Pendant l’anesthésie générale, avec le même objectif on administre des bloqueurs adrénergiques (labétalol 1,0 mg · kg−1 et esmolol 0,75 mg · kg−1) avec du nitroprussiate de soude 1,5 μ · kg−1 (dose totale). Avant la naissance, les opiacés sont évités dans le but de prévenir la dépression foetale. Après la naissance, du sufentanil 0,4 μ · kg−1 · h−1 permet de limiter la concentration d’inhalatoire pour prévenir l’atonie utérine. La douleur postopératoire est traitée avec une perfusion morphinique. La mère et l’enfant récupèrent sans complications.
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Joffe, D., Robbins, R. & Benjamin, A. Caesarean section and phaeochromocytoma resection in a patient with Von Hippel Lindau disease. Can J Anaesth 40, 870–874 (1993). https://doi.org/10.1007/BF03009260
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DOI: https://doi.org/10.1007/BF03009260