Rev. Bras. Anestesiol. vol.67 número2

RevBrasAnestesiol.2017;67(2):210---213

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Anesthetic

management

of

an

infant

with

giant

abdominal

neuroblastoma

Manuel

Ángel

Gómez-Ríos

_,

_Federico

_Curt

_Nu˜

_no,

_Purísima

_{Barreto-Calvo}

ComplejoHospitalarioUniversitariodeACoru˜na,DepartamentodeAnestesiologíayMedicinaPerioperatoria,ACoru˜na,Spain

Received6July2014;accepted21July2014 Availableonline8November2014

KEYWORDS

Neuroblastoma; Pediatricanesthesia; Infant;

Hypertension

Abstract Neuroblastomaisthemostcommon,non-centralnervoussystemtumorofchildhood. Ithas thepotential to synthesizecatecholamines. However, the presences ofhypertension areuncommon.Wereporttheperioperativemanagementofa15-month-oldinfantwithgiant abdominalneuroblastomawho presentedseverehypertension.Thepathophysiological alter-ationsofneuroblastomaarereviewedandperioperativemanagementpresented.

©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Neuroblastoma; Anestesiapediátrica; Crianc¸a;

Hipertensão

Manejoanestésicodecrianc¸acomneuroblastomaabdominalgigante

Resumo Neuroblastoma é otumor mais comum do sistema nervoso não-centralna infân-cia. Esse tumor tem o potencial para sintetizar catecolaminas; entretanto, a presenc¸a de hipertensão érara. Relatamos o manejoperioperatório deuma crianc¸a de cinco mesesde idadecomneuroblastomaabdominalgigantequeapresentouhipertensãograve.Asalterac¸ões fisiopatológicasdoneuroblastomaforamrevistaseomanejoperioperatórioapresentado. ©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Neuroblastomaisthemostcommonextracranialsolidtumor

in childhood.1 _{It affects yearly 6---10 million of children,}

∗_{Correspondingauthor.}

E-mail:magoris@hotmail.com(M.Á.Gómez-Ríos).

accounting7---8% ofpediatrictumors.Clinicalpresentation

is highly variable depending on location. It may include

nonspecific signs and symptoms such as abdominal pain,

vomiting,weightloss,anorexia,fatigue,diarrheaand

pal-pable mass.2 _{Its origin is embryonic, developing from}

postganglionic sympathetic nerve fibers, and it can be

associatedwithelevatedlevelsofcatecholamine’s.

Never-thelesshypertensionisuncommon,beingpresentin10---27%

http://dx.doi.org/10.1016/j.bjane.2014.07.012

0104-0014/©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC

Anestheticmanagementofaninfant 211

Figure1 Infantafteranestheticinduction.

ofcases.3_{Possiblemultiorganicaffectation,mainlyeffects}

in cardiovascular and respiratory system, as well as the

treatmentofseverehypertensiondeservetobereviewed.

The parentsofthe patientgavewritteninformedconsent

forpublicationofthisarticle.

Case

report

A 15-month-old, 8.5kg boy was admitted on the

emer-gencydepartment of ourinstitution, withfatigue, partial

rejection of intake, weight loss, vomiting and abdominal

distension (Fig. 1). Laboratory testing revealed

hyper-uricemia (7.1mg/dL), hypoalbuminemia (3.2g/dL), LDH

4205.0IU/L, sodium 129.0mEq/L, potassium 3.5mEq/L,

chloride90.0mEq/L.AbdominalMRIshowedalarge

abdom-inalmass(12cm×10cm×10cm)encompassingmesentery

and retroperitoneum and compressed and displaced both

kidneys,surroundingcircumferentiallytheaortaandrenal

arteries and veins (Fig. 2). Persistent severe

hyperten-sionwaspresent(180---120mm/Hg).Echocardiographyruled

out the presence of associated heart disease.

Intra-venousinfusionofsodiumnitroprusside(0.5---3mg/kg/min)

was administered for acute blood pressure control. After

72h, sequential oral treatment was started with

cloni-dine (20mg/6h), nifedipine (4mg/6h) and propranolol

(3mg/8h),reachingastablemeanarterialpressuretarget

Figure2 AxialMRIshowsthegiantintraabdominalmass.

of 100mm/Hg. A MAPlower than 100mm/Hg determined

a critical decrease in tissue perfusion pressure reflected

withtheestablishmentofoligoanuria.Hewastakentothe

operatingroom for a series of biopsies (abdominal mass,

bone marrow and lymph nodes) to confirm the

diagno-sis.Rapid sequence induction wasperformed withSellick

maneuverafteradequatepreoxygenationwith100%oxygen,

andanesthesiainductionwithremifentanil(0.2␮g/kg/min),

propofol (2.5mg/kg), rocuronium (1.2mg/kg) and

lido-caine(1mg/kg).Trachealintubationproducednosignificant

changesin vitalsigns. The pressure-controlledventilation

was adjusted to maintain normocapnia using a mixture

of oxygen-air(FiO 50%). Maintenance of general

anesthe-sia was carried out using sevoflurane and remifentanil

(0.2---0.6␮g/kg/min).Persistedhypertensionwascontrolled

withestablishedantihypertensivetreatmentandincreasing

dosesof remifentanilduringthesurgery. Aftercompletion

of the surgical procedure infant was transferred to the

PICUmaintainingintravenousinfusionofsodium

nitroprus-side.Thediagnosisofneuroblastomawasconfirmed.Urine

catecholamine’s or their metabolites were undetectable.

Thesubsequentchemotherapyandtumorresectionallowed

restorationofnormalbloodpressure.

Discussion

Neuroblastoma derives from cells of neural crest, which

canbelocated at anyplacewhere thesearepresent and

theyretainthepotentialtosynthesizecatecholamines.Both

featuresaredeterminantsofassociatedpathophysiological

alterations.4

Itslocationisusuallyintraabdominal,althoughitis

pos-sible intrathoracic or cervical location and may produce

airway compromise. The presence of an abdominal mass

increases intra-abdominal pressure (IAP).1 _{This increases}

therisk of aspirationtherefore, rapid sequence induction

is recommendable. In the respiratory system it

deter-minescephalicdisplacement of thediaphragm,increasing

intrathoracicpressureanddecreasinglungcomplianceand

functional residual capacity, which determines a greater

tendency to pulmonary atelectasis, impaired ventilation

perfusion ratio after induction of general anesthesia and

hypercapniaandhipoxemia.Itproducespulmonary

vasocon-strictionandincreasesthegasexchangeimpairmentinthe

alveolar-capillaryunit.Theextentofchangesinthe

cardio-vascularsystemisdependentonthemagnitudeoftheIAP,

presence of cardiomyopathy, intravascular volumestatus,

mode of mechanical ventilation, surgical conditions, and

anestheticagents employed.Systemic vascular resistance

increasesduetomechanicalcompressionoftheabdominal

aorta,highlevelsofneurohumoralfactorslikevasopressin, activationoftherenin---angiotensin---aldosteronesystemand

compressionoftherenalarteries,leadingtohypertension.

This high afterloadincreases the risk of acute pulmonary

edema. Compression of the inferior vena cava reduces

preloadandcardiacoutputdecreasingtissueperfusion,

par-ticularlyinpresenceofhypovolemia.Tachyarrhythmiasare

frequentduetohypercapnia andincreasedlevelsof

circu-latingcatecholamines.Allthesechangesmaydecreaseafter

laparotomyduetodecompressionoftheabdominalcavity,

212 M.Á.Gómez-Ríosetal.

Table1 Commondrugsusedtotreathypertensioninpediatricpatients.

Drug Routeof administration

Dose Notes

Clonidine PO 5---10g/kg24h(2---4doses) ␣2-adrenergicagonist.Riskofprolongedsedation. Nifedipine PO 0.25---0.5mg/kg4---6h Dihydropyridinecalciumantagonist.

Predominantlyvasculareffects. Propranolol PO/IV 0.05---0.2mg/kgiv

0.5---1mg/kg24h(3---4 doses)vo

Nonselective␤blockade.Riskofbronchospasm, myocardialdysfunction,AVblockand

hypoglycemia.

Labetalol IV 0.25---1mg/kg/h Nonselectiveblockade.Sideeffectsaresimilarto thoseofpropranolol.

Esmolol IV 50---200␮g/kg/min Relativelyselectiveblockade.Shorthalf-life (10min).

Sodium nitroprusside

IV 0.5---10␮g/kg/min Potentdirectrelaxationofvascularmuscletissue, botharteriolarandvenouscapacitancevessels. Potentialcyanidetoxicity;reflextachycardia. Nitroglycerin IV 0.5---10␮g/kg/min Directsmoothmusclerelaxation,predominantly

ofvenouscapacitancevessels.

Phentolamine IV 0.5---5␮g/kg/min Selectiveblocker,mainlyarteriolarvasodilation. Hydralazine IV 0.1---0.2mg/kg6h Directsmoothmusclerelaxation,predominantly ofarteriolar.Longhalf-life.Tachyphylaxis;reflex tachycardia;thrombocytopenia;lupus-like syndrome.

Urapidil IV Initially:2mg/kg/h Maintenance:0.8mg/kg/h. Max.7days

Electiveantagonistofperipheralpostsynaptic 1-adrenergicreceptors.

Enalapril PO/IV 0.1---0.5mg/kg24h(1---2 doses)PO

5---10␮g/kg8---24hiv

Angiotensinconvertingenzymeinhibitor.Effectof longduration.Hyperkalemia,renalfailure, angioedema;severehypotensionwithanesthetic agents.

PO,Orally;IV,intravenously.

Hypertension, in addition to the above mechanisms, can result from the vasoconstrictor action of cate-cholamines secreted by the tumor or the stimulation of the renin---angiotensin---aldosterone system secondary to compression of the renal artery. There may be an associated cardiomyopathy but it is uncommon. Its etiology is multifactorial3_{; it includes}

catecholamine-induced vasoconstriction, coronary vasospasm, chronic

tachycardiomyopathysecondarytoahyperadrenergicstate,

b-adrenergicreceptors down regulation and promotion of

calciuminfluxintosarcolema.Effectivetreatmentof

hyper-tensionbeforesurgeryismandatorytoreduceperioperative

morbidityandmortality.Intraoperativehypertensive crisis

mayoccur,especiallyduringtrachealintubation,anesthetic

induction and tumor manipulation. Thus, it is critical to

minimize the sympathetic response secondary to direct

laryngoscopy.5 _{Thiopental, succinylcholine, and morphine}

shouldbeusedwithcautionduetocatecholamine release

secondarytohistaminereleasefrommorphineorthiopental,

increased abdominal pressure or sympathetic stimulation

following succinylcholine.2 _{Intraoperative hypertension in}

patients with catecholamine secreting neuroblastomas is

controlledusingshort-acting agents suchassodium

nitro-prusside,calciumantagonists,phentolamine,adenosineor

prostaglandinE1.2_{Theuseofantihypertensivedrugsin}

pedi-atricpatients shouldbeinitiated in thelower dose under

close cardiovascular monitoring and titrated to effect.6,7

Table1showsthedrugscommonlyusedfortreating hyper-tensioninpediatricpopulation.

Management of patients with giant abdominal

neuro-blastoma is an anesthetic challenge. The knowledge of

pathophysiological implications and the adequate

antihy-pertensivetreatmentareessentialforsuccessfulanesthetic

management.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.HammerG,HallS,DavisPJ.Anesthesiaforgeneralabdominal, thoracic,urologic,andbariatricsurgery.Neuroblastoma proce-dures.In: Davis PJ,Cladis FP, Motoyama EK, editors.Smith’s anesthesiaforinfantsandchildren.8thed.Philadelphia:Elsevier Mosby;2006.p.754---5.

2.Seefelder C, Sparks JW, Chirnomas D, et al. Periopera-tive management of a child with severe hypertension from a catecholamine secreting neuroblastoma. Paediatr Anaesth. 2005;15:606---10.

Anestheticmanagementofaninfant 213

4.KainZN,Shamberger RS,HolzmanRS.Anestheticmanagement ofchildrenwithneuroblastoma.JClinAnesth.1993;5:486---91.

5.Kako H, Taghon T, Veneziano G, et al. Severe intraoperative hypertensionafterinductionofanesthesiainachildwitha neu-roblastoma.JAnesth.2013;27:464---7.

6.Cladis FP. Pediatric drug dosages. In: Davis PJ, Cladis FP, Motoyama EK, editors. Smith’s anesthesia for infants

and children. 8th ed. Philadelphia: Elsevier Mosby; 2006 [AppendixA].