Lentschener C, Gaujoux S, Thillois J M, Duboc D, Bertherat J, Ozier Y, Dousset B
Department of Anaesthesia and Critical Care, Université Paris-Descartes, Faculté de Médecine, Paris, France.
Acta Anaesthesiol Scand. 2009 Apr;53(4):522-7. doi: 10.1111/j.1399-6576.2008.01894.x. Epub 2009 Feb 19.
Pre-operative hypotensive drugs are assumed to have dramatically decreased operative mortality and morbidity in patients undergoing phaeochromocytoma removal only in non-controlled studies. We evaluated the predictive value of pre-operative high systolic arterial pressure (SAP) on intra- and post-operative haemodynamic instability, in 96 patients undergoing laparoscopic adrenalectomy for phaeochromocytoma.
Ninety-six consecutive patients underwent laparoscopic adrenalectomy for phaeochromocytoma. Pre-operative SAP was not systematically normalised, provided that increased SAP was clinically tolerated. Intravenous nicardipine, esmolol and norepinephrine were intraoperatively titrated to treat SAP increase >150 mmHg, tachycardia >90-110/min, arrhythmia or SAP decrease under 90 mmHg, respectively. Volume expanders were not systematically administered. Patients with increased and normal pre-operative SAP were compared with respect to (a) nicardipine, esmolol and norepinephrine requirement, (b) highest intraoperative SAP and heat rate, (c) lowest intraoperative SAP, (d) duration of surgery and (e) norepinephrine requirement following tumour removal.
Groups did not differ significantly with respect to data defined as being indicative of perioperative haemodynamic instability (all P values>0.05).
As previously demonstrated, in patients undergoing phaeochromocytoma removal, perioperative haemodynamic changes are mainly due to catecholamine release during tumour manipulation, and to the decrease in catecholamine level following tumour removal. Whether pre-operative hypotensive drugs are likely to alter these changes remains questionable.
For most patients scheduled for laparoscopic phaeochromocytoma removal, surgery can be carried out without systematic pre-operative arterial pressure normalisation.
仅在非对照研究中，术前降压药物被认为可显著降低嗜铬细胞瘤切除患者的手术死亡率和发病率。我们评估了术前高收缩压（SAP）对96例接受腹腔镜肾上腺嗜铬细胞瘤切除术患者术中和术后血流动力学不稳定的预测价值。
96例连续患者接受腹腔镜肾上腺嗜铬细胞瘤切除术。如果临床可耐受升高的SAP，则术前SAP未进行系统的正常化处理。术中分别滴定静脉注射尼卡地平、艾司洛尔和去甲肾上腺素，以治疗SAP升高>150 mmHg、心动过速>90 - 110次/分钟、心律失常或SAP降低至90 mmHg以下。未系统给予容量扩张剂。比较术前SAP升高和正常的患者在以下方面的情况：（a）尼卡地平、艾司洛尔和去甲肾上腺素的需求量；（b）术中最高SAP和心率；（c）术中最低SAP；（d）手术持续时间；（e）肿瘤切除后去甲肾上腺素的需求量。
在定义为围手术期血流动力学不稳定的数据方面，两组之间无显著差异（所有P值>0.05）。
如先前所示，在接受嗜铬细胞瘤切除术的患者中，围手术期血流动力学变化主要是由于肿瘤操作期间儿茶酚胺释放，以及肿瘤切除后儿茶酚胺水平降低。术前降压药物是否可能改变这些变化仍存在疑问。
对于大多数计划进行腹腔镜嗜铬细胞瘤切除术的患者，手术可以在不进行系统术前动脉压正常化的情况下进行。
