Original Contribution
Catecholamine release induces elevation in plasma lactate levels in patients undergoing adrenalectomy for pheochromocytoma

https://doi.org/10.1016/j.jclinane.2014.06.005Get rights and content

Highlights

  • The relationship between preoperative catecholamine levels and intraoperative peak plasma lactate levels were studied in patients who underwent adrenalectomy for pheochromocytoma.

  • Catecholamine release from the tumor by surgical manipulation is one of major causes of complications, hindering perioperative management.

  • Intraoperative peak plasma lactate level was correlated with preoperative epinephrine-releasing activity.

  • Catecholamine release from surgical manipulation may be a cause of intraoperative transient lactic acidosis.

  • Catecholamine release should be thought of as a differential diagnosis of intraoperative lactic acidosis.

Abstract

Study Objective

To determine the relationship between preoperative catecholamine levels and intraoperative peak plasma lactate levels in patients who underwent adrenalectomy for pheochromocytoma.

Design

Retrospective observational study.

Setting

Operating room in one university hospital.

Measurements

The records of 27 ASA physical status 1 and 2 patients who underwent adrenalectomy for pheochromocytoma were studied. Preoperative catecholamine levels and intraoperative plasma lactate levels were recorded.

Main Results

Twenty cases had high lactate levels (> 2 mmol/L). Preoperative urine epinephrine levels and urine metanephrine levels showed a moderate correlation with intraoperative peak plasma lactate levels (rs = 0.475 and rs = 0.499, respectively; Spearman’s rank correlation test). Receiver operating characteristic (ROC) curve analysis for preoperative urine epinephrine levels showed good performance for prediction of high lactate levels [> 2 mmol/L, area under the curve (AUC) = 0.800], whereas ROC for preoperative urine norepinephrine levels showed no predictive performance for high lactate levels.

Conclusions

Catecholamine release caused by surgical manipulation may be a possible cause of intraoperative transient lactic acidosis, and it should be considered as a differential diagnosis of intraoperative lactic acidosis. Intraoperative peak plasma lactate level was correlated with preoperative epinephrine-releasing activity.

Introduction

Pheochromocytoma is a catecholamine-producing neuroendocrine tumor derived from chromaffin cells of the adrenal medulla or extra-adrenal paraganglia [1], [2]. Tumor resection is the most effective treatment approach, although severe perioperative complications may occur. Intraoperative catecholamine release from the tumor by surgical manipulation is one of the major factors for complications, which makes perioperative management difficult, even in cases treated with a sufficient dose of antihypertensive drugs preoperatively.

Previous studies have reported cases of pheochromocytoma with elevation of plasma lactate levels [3], [4], [5], [6]. Despite these clinical reports, lactic acidosis is categorized as a relatively uncommon perioperative complication of pheochromocytoma, likely because of lack of accumulated data. Therefore, whether surgically-induced catecholamine release resulted in elevation of plasma lactate level was studied in a series of patients who underwent adrenalectomy for pheochromocytoma. Intraoperative changes in plasma lactate levels over time was assessed, and the relationship between preoperative urine/plasma catecholamine levels and intraoperative peak lactate levels was determined.

Section snippets

Materials and methods

The study protocol was approved by the local institutional ethical committee (Research ID-Med 1344; Ethical Committee, Tokyo Medical and Dental University, Faculty of Medicine), which waived the need for informed consent. The data collection for this study was retrospective and observational. All the data were based on routine clinical recordings.

Results

All 27 patients clinically diagnosed with pheochromocytoma underwent minimum incision endoscopic surgery technique without CO2 inflation, and postoperative pathologic examination confirmed the diagnosis of pheochromocytoma in all patients. Patient and surgical characteristics are summarized in Table 1. When patients undergoing adrenalectomy for pheochromocytoma were compared with those with Cushing syndrome, the tumor size was significantly larger (median 44 mm, IQR 32–64 mm vs median 30 mm,

Discussion

Preoperative urine levels of epinephrine and metanephrine were positively correlated with peak plasma lactate levels during surgical pheochromocytoma resection. In contrast, neither norepinephrine nor normetanephrine showed a significant correlation. In all cases, plasma lactate levels peaked at tumor removal, then decreased by the end of surgery. Further, plasma lactate levels at tumor removal in pheochromocytoma patients were significantly higher than those in patients with Cushing syndrome.

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There are more references available in the full text version of this article.

Supported by departmental funding only.

1

These authors contributed equally to this work.

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