Use of a ‘hospital-at-home’ service for patient optimization before resection of phaeochromocytoma

C. E. Emerson and A. Rainbird*

Department of Anaesthesia, The Queen Elizabeth Hospital, Woodville Road, Woodville, Adelaide, SA 5011, Australia

Corresponding author. E-mail: alan.rainbird@nwahs.sa.gov.au

Accepted for publication: October 22, 2002


    Abstract
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
The perioperative management of phaeochromocytoma remains a complicated anaesthetic challenge, often requiring a prolonged preoperative hospital stay or numerous outpatient clinic visits. This is not only inconvenient for the patient, it also puts them at additional risk of acquiring hospital infections and is expensive to the health service. We present a patient with a phaeochromocytoma who was successfully managed preoperatively with phenoxybenzamine in the community by a ‘hospital-at-home’ service. She required no other antihypertensives before operation, although glyceryl trinitrate and magnesium sulphate were used before induction of anaesthesia. Apart from intervention for a chest infection on day 3, she had a relatively smooth hospital course and returned home on day 13. We suggest that this may be an appropriate management option for selected patients.

Br J Anaesth 2003; 90: 380–2

Keywords: complications, phaeochromocytoma; surgery, phaeochromocytoma


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Phaeochromocytoma is a rare, potentially fatal tumour. Patients with such tumours present a major challenge to the anaesthetist during surgery. The need for thorough preoperative optimization of the patient is well recognized. There has been a decrease in mortality associated with resection from 40–60% to 0–6% over the past 50 yr.1 Traditionally, these patients have been managed either as in-patients for up to two weeks or by daily outpatient clinic visits. We present a case of preoperative management and optimization of a patient through a ‘hospital-at-home’ service.


    Case report
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 50-yr-old woman was referred to our Perioperative High Risk Clinic by a urologist. She had originally presented to her general practitioner (GP) complaining of headaches and loin pain. On finding her to be hypertensive, the GP referred her to an endocrinologist who initially excluded phaeochromocytoma by an equivocal clonidine suppression test. However, a urological opinion, sought because of her loin pain, led to the discovery of a large 10 x 10 x 8 cm left adrenal mass, which was confirmed as phaeochromocytoma after a [131I]meta-iodobenzyl guanidine (MIBG) scan. The patient was initially keen to delay surgery for social reasons but, following discussions with the relevant anaesthetist and surgeon, she began to appreciate the severity of her condition and she agreed to proceed promptly.

On her first appointment with the anaesthetist, she had a blood pressure of 140/90 mm Hg, and a heart rate of 94 beats min–1, and was slightly obese (89 kg). She was otherwise reasonably well, apart from cigarette-related ‘asthma’, and was not taking any regular medication. She lived locally and had a strong social support network at home. It was arranged for her to be managed there before her operation. The Queen Elizabeth Hospital provides a hospital-at-home service as one of the functions of the Convalescent Unit. Patients are classified as inpatients for funding purposes, and the unit operates within a separate hospital budget. Hospital-at-home nurses are full-time employees of the hospital. They had not been approached previously with regard to such preoperative preparation, but undertook the task enthusiastically.

At a subsequent outpatient visit, a member of the hospital-at-home team met the patient and a plan of action was agreed upon by all the staff involved in the patient’s care. The patient was given a supply of phenoxybenzamine from the hospital pharmacy, with instructions for a starting dose of 10 mg twice daily. A nurse then visited her daily for a week, when supine and erect blood pressures were measured, and adequate oral fluid intake ensured. The nurse would then contact the consultant anaesthetist and the dose of phenoxybenzamine was adjusted accordingly. The anaesthetist was available to both the nurse and patient at all times, via a pager and mobile phone. The patient was satisfied with the management and did not initiate any contact. Nevertheless, the anaesthetist contacted the patient on three occasions to assess progress. Her supine blood pressure was consistently measured at 150/90 mm Hg, with erect values of the order of 115/75 mm Hg after the dose of phenoxybenzamine had been increased. She did not become tachycardic and did not require ß-blockade. The only side-effect of phenoxybenzamine was mild light-headedness on standing after her final dose increase, commensurate with a postural drop in blood pressure to 110/65 mm Hg. The patient was admitted to hospital the day before surgery. By this time she was taking phenoxybenzamine 30 mg twice daily and no other medication. Her blood pressure was 130/80 mm Hg lying, 115/75 mm Hg standing, and her heart rate was 80 beats min–1.

Phenoxybenzamine was omitted on the morning of surgery. A thoracic epidural, central venous catheter inserted via a 9FrG percutaneous sheath, and arterial line were placed before operation. She was preloaded with saline 0.9%, 3 litres, and Gelofusine 500 ml (B. Braun Australia Pty Ltd, Castle Hill, NSW, Australia), and a glyceryl trinitrate infusion was commenced at 10 µg min–1 to facilitate preloading. Magnesium sulphate was administered as a bolus of 3.5 g before induction, according to the procedure previously established,2 with an ongoing infusion of 2 g h–1. Induction was performed uneventfully with remifentanil 1 µg kg–1 and propofol as a target-controlled infusion, with an initial target of 4 µg ml–1. The incision was to be thoracolumbar and so, after muscle paralysis with succinylcholine 150 mg, she was intubated with a 37FrG double-lumen tracheal tube and turned to the left lateral position. Anaesthesia was maintained with propofol, requiring a target range of 2.5–3 µg ml–1, and a remifentanil infusion at 0.2 µg kg–1 min–1. Continued neuromuscular block was obtained using increments of rocuronium to a total dose of 90 mg. A low-dose epidural infusion of ropivacaine 2 mg ml–1 and fentanyl 2 µg ml–1 was also used. Her cardiovascular variables remained stable throughout the operation, which was complicated by bleeding from the splenic vein, necessitating a splenectomy. Extubation was uneventful and she was transferred to the recovery ward, where she spent an uneventful night, requiring no antihypertensive treatment. She required continuous positive airway pressure 3 days after operation for a chest infection/atelectasis, but responded well. She remained normotensive and was discharged home on day 13 on no medication.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Phaeochromocytoma is a topic which always invites much discussion, primarily on the preoperative optimization of these patients with {alpha}-adrenergic block, using either phenoxybenzamine3 or specific {alpha}1 blocking agents,4 and on the intraoperative management.2 5 However, we could find no published literature on the possibility of managing suitable patients at home before operation.

Now, more than ever, there is an increased demand for the limited resources of the public health system. With the average hospital bed in Australia costing between A$400 and 600 per night, and the ever-increasing bed pressures, there is an ongoing drive to increase the efficiency of hospital services. The introduction of day-of-surgery admission for elective surgery and increasing rates of day-case procedures have led to a decrease in inpatient bed occupancy rates.6 Conditions that not long ago required prolonged hospital admission can now be managed in the community. For example, deep-vein thrombosis is now commonly managed at home by the daily administration of low molecular weight heparin.7

The preoperative optimization of patients undergoing phaeochromocytoma resection requires careful monitoring of blood pressure and gradual increase in the dose of phenoxybenzamine prescribed. In this case, monitoring was provided by daily visits from the hospital-at-home nursing staff, who liaised directly with the consultant anaesthetist managing the patient for alterations in drug dose. The individual care and attention provided by this service is likely to be at least as good as that found on an overly busy surgical ward or in an outpatient clinic.

In addition to the fiscal benefits to the health service at large, there are potential benefits to individual patients. The management of these patients at home is likely to be beneficial on a number of levels. First, it allows the patient to lead an essentially normal life until just before their operation. Second, the patient is not isolated from their support network, as can happen on admission to hospital. Finally, and possibly most importantly, the exposure of the patient to hospital-acquired infection is kept to a minimum.

Clearly, this approach will not be suitable for all patients. Acceptable criteria would include absence of significant comorbidities and pre-existing medications, satisfactory social support and a motivated patient. The medical team must be assured that the patient comprehends the process and will comply with medication, fluid intake and lifestyle restriction, such as absence from work. There should be provision for an outpatient review if a longer preparation time is expected and provision for admission if the preparation is not smooth (e.g. the development of tachycardia warranting the introduction of ß-blockade). However, if all parties are satisfied that the arrangements are safe and provide equivalent preoperative preparation, it is a management option to be considered.


    References
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Roizen M. Anaesthetic implications of concurrent diseases. In: Miller RD, ed. Anaesthesia Vol. 1. New York: Churchill Livingstone, 1994; 922

2 James MF. Use of magnesium sulphate in the anaesthetic management of phaeochromocytoma: a review of 17 anaesthetics. Br J Anaesth 1989; 62: 616–23[Abstract]

3 Hull CJ. Phaeochromocytoma. Diagnosis, preoperative preparation and anaesthetic mangement. Br J Anaesth 1986; 58: 1453–68[Abstract]

4 Prys-Roberts C. Phaeochromocytoma—recent progress in its management. Br J Anaesth 2000; 85: 44–57[Free Full Text]

5 Combemale F, Carnaille B, Tavernier B, et al. Exclusive use of calcium channel blockers and cardioselective beta-blockers in the pre- and per-operative management of phaeochromo cytoma. 70 cases. Ann Chir 1998; 52: 341–5[ISI][Medline]

6 MacIntyre CR, Brook CW, Chandraraj E, Plant AJ. Changes in bed resources and admission patterns in acute public hospitals in Victoria, 1987–1995. Med J Aust 1997; 167: 186–9[ISI][Medline]

7 Schraibman IG, Milne AA, Royle EM. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev 2001: CD003076