Anaesthetic management of an undiagnosed pheochromocytoma in a patient undergoing a radical nephrectomy

Pheochromocytomas are rare neoplasia in the adrenal medulla formed by chromaffin cells that produce catecholamines. The incidence is about 2 to 8 cases per million with a peak incidence between the 4th and 5th decade of life. Pheochromocytomas are a cause of secondary hypertension only in 0.1% of the population with hypertension. Headache, palpitation, diaphoresis, flushing and paroxysmal hypertension are classic symptoms. The most frightening complications are hemorrhagic stroke, heart failure and heart attack, those are main causes of mortality in these kinds of patients. Surgery is a high-risk procedure requiring perioperative management by a specialized multidisciplinary team in centers with broad expertise. Case presentation: A 50-year-old male with a left renal mass diagnosed by CT scan that measured 14X14 cm. In the intraoperative period, while manipulating the tumor, the patient presents a hemodynamic instability, reaching blood pressure of 395/190 mmHg (reported by the invasive monitorization). During the hypertensive crisis, we start immediately the intravenous administration of esmolol, dexmedetomidine, nifedipine, magnesium sulphate and lidocaine, and peridural ropivacaine. Besides the anesthetic management with fentanyl, sevoflurane and cisatracurio. After this management, the blood pressure decreases, the tumor removal and extubating are done successfully. There is very little information about the intraoperative management of this neoplasia, only a few case reports about the intraoperative management of pheochromocytoma have been published in the literature. In this case, the diagnosis of pheochromocytoma was made by the pathology department after the surgery in the postoperative period.