(1547) Management of Multifactorial Shock in Pheochromocytoma

Tuesday, February 25, 2025

12:30pm – 1:30pm Eastern Time

Location: Connections Central - RST 10

First Author(s)

Yong Lee, MD

Cooper University Hospital, USA

Co-Author(s)

RS

Ryan Sullivan, DO

Cooper University Hospital
Cooper Medical School at Rowan University, USA
Nitin Puri, MD

Division Head and Co-Medical Director, Critical Care Medicine, Intensivist, Associate Professor
Cooper University Hospital
Camden, NJ, United States

Introduction: Pheochromocytoma is a rare neuroendocrine tumor with excess production of catecholamines, but incidences with shock are much more infrequent. While there are documented case reports of shock in pheochromocytoma, this case reviews an approach to management and considerations.

Description: A 61-year-old male with left adrenal pheochromocytoma and stage IV colon cancer was admitted to the ICU for hemorrhagic shock with adrenal insufficiency. A CT scan revealed a left retroperitoneal hematoma with bleeding, alongside abnormally normal cortisol level, and severe fluctuations in blood pressure ranging from 50/30 to 250/200mmHg. The patient was treated with a balanced massive transfusion and crystalloids. Vasopressin and phenylephrine were used to manage hypotension due to patient’s hypersensitivity to catecholamines predisposing to dysrhythmias. Furthermore, adrenal insufficiency was addressed with hydrocortisone and fludrocortisone. After these initial measures, embolization was pursued. The left adrenal mass was noted to be bleeding, which was successfully embolized. Following embolization, patient’s overall hemodynamics improved and stabilized. He rapidly recovered and on post procedure day 1, his shock state had resolved as evidenced by lack of hypotension, normalized lactic acid, and lack of evidence of end organ dysfunction. He became intermittently hypertensive due to the pheochromocytoma, which was managed with phentolamine then transitioned to prazosin for long-term alpha blockade.

Discussion: Management of shock in pheochromocytoma poses challenges due to unpredictable hemodynamic fluctuations. Identifying the underlying cause of the shock and determining the appropriate management strategy is important. While there are case reports of spontaneous adrenal hemorrhage in pheochromocytoma patients, this case emphasizes the importance of prompt intervention, such as embolization, as a key component of the treatment approach for shock in pheochromocytoma. Although phentolamine is recommended for perioperative management, its availability should not delay timely intervention.