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\title{Continuous blood purification in patients with pheochromocytoma crisis:
A case report}



\author[1]{Meinong Zhong}%
\author[1]{Yuanqiang Zhu}%
\author[1]{Shaofang Wang}%
\author[1]{Hengying Fang}%
\author[1]{Guili Chen}%
\affil[1]{Third Affiliated Hospital of Sun Yat-Sen University}%


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  \date{June 02, 2024}


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\emph{INTRODUCTION}

Pheochromocytoma, arising from the chromaffin cells of the adrenal
medulla, can cause excessive catecholamines secretion and trigger
pheochromocytoma crisis, characterized by high mortality rate up to
13\%\textsuperscript{1}. Pheochromocytoma crisis induced
catecholaminergic cardiomyopathy may lead to multiple organ system
damage or dysfunction, myocardial infarction, acute left ventricular
failure, cardiogenic shock, and other fatal outcomes, commonly in
undiagnosed or well-controlled pheochromocytoma\textsuperscript{2}.
Surgical resection is the primary treatment; however, the instability of
perioperative hemodynamics poses a high risk of anesthesia and poses
great challenges in treatment\textsuperscript{3}. Currently, research on
the diagnosis, treatment, and nursing care of such patients is mainly
based on case reports. Veno-arterial extracorporeal membrane oxygenation
(VA -ECMO) has been reported to stabilize circulation and extend the
surgical window for patients with severe myocardial injury or
circulatory failure\textsuperscript{4}. In June 2021, we successfully
treated a patient with pheochromocytoma presenting with cardiogenic
shock as the first manifestation of multiple organ failure. This case
report presents our experience in diagnosis, treatment, and nursing care
of pheochromocytoma with various severe complications.

\emph{CASE PRESENTATION}

Case data

A previously healthy 32-year-old woman experienced a sudden choking
cough while eating ice cream on May 8, 2021, which caused progressive
chest tightness, shortness of breath, and dyspnea. This patient was
diagnosed with severe pneumonia, acute left heart failure, cardiogenic
shock, and giant pheochromocytoma (Figure 1). Initial treatment in local
hospital included tracheal intubation, VA-ECMO combined with CRRT
treatment, \selectlanguage{greek}α-\selectlanguage{english}blockers (phentolamine), \selectlanguage{greek}β-\selectlanguage{english}blockers (propranolol), and
other support care. After 10 days of treatment, the left ventricular EF
increased from 8\% to 67\%, and ECMO support was withdrawn. Right
femoral vein vascular repair was performed(Figure 2),and CRRT was
reserved, while the patient developed sepsis. The patient was then
transferred to our hospital on June 3 for further treatment. Subsequent
treatment at our hospital involved anti-infection, anti-heart failure,
volume expansion, CRRT, phentolamine, propranolol, lyophilized
recombinant human brain natriuretic peptide, and morphine, alongside
meticulous wound care. CRRT treatment was suspended on June 9. On June
15, patient was transferred to the general ward for further preparation,
but experienced another pheochromocytoma crisis during the bumpy
transfer, resulting in multiple organ failure and malignant arrhythmia.
Prompt intervention including nasal high-flux oxygen therapy, CRRT, and
other treatments stabilized patient's condition. On June 18,
laparoscopic left adrenal giant pheochromocytoma resection was
successfully performed under general anesthesia with CRRT support.
Postoperatively, the patient exhibited favorable wounds healing,
significant reduction in plasma catecholamine metabolites to nearly
normal level, and was subsequently discharged. All treatments described
were administered with the patient's informed consent. During a
six-months follow-up, the patient remained asymptomatic, with normal
hormone levels.

CRRT treatment strategy

The patient underwent dialysis catheter insertion via the internal
jugular vein. Continuous blood purification was conducted using
Prismaflex (Gambro, Jinbao, Sweden). The supporting hemodialysis filter
and the hemofiltration replacement base fluid was provided by Chengdu
Qingshan Likang Pharmaceutical Co.,Ltd., National Medicine Zhunzi
H20080452. The treatment was set to continuous venous-venous
hemodiafiltration mode (CVVHDF) at a rate of 25-45 ml/kg/h, with a blood
flow rate of 120-150 ml/min. Citric acid anticoagulation for CRRT was
administered during June 4-9 at a dose of 180-220 ml/h, adjusted based
on the serum calcium levels. On June 15, due to impaired liver function
and D-dimer exceeding 20ug/ml, the anticoagulation method was switched
to low molecular weight heparin sodium at a dose of 0.4 ml every 8
hours. Surgical intervention was performed on June 18 without
anticoagulation to reduce bleeding risk. The efficacy of CRRT treatments
were recorded in Table 1-3.

\emph{DISCUSSION}

This patient experienced cardiogenic shock due to pheochromocytoma
crisis. Early administration of ECMO treatment in the local hospital
with other subsequent treatments were crucial in saving the patient's
life and improving their survival rate. Unfortunately, ECMO had to be
discontinued because of secondary severe bloodstream infection, possibly
caused by emergency catheterization. To address this, CRRT was used as
it has demonstrated effectiveness in removing toxins and inflammatory
mediators, regulating internal environment and improving circulatory
function in cases of multiple traumas and acute kidney
injury\textsuperscript{5}. Given the high technical requirements, cost,
and patient limitation associated with ECMO, CRRT was continued even
after the patient was transferred to our hospital. The results in Table
1 show that prolonged CRRT treatment gradually decreased norepinephrine
level in the patient's body. In this case report, CRRT effectively
eliminated catecholamines metabolites. However, the patient developed
sepsis, along with toxins and inflammatory cytokines in the circulation.
During the acute attack, the patient experienced heart, liver, and
kidney damaged, leading to circulatory failure, hemodynamic
fluctuations, and inflammatory cytokine secretion. Table 2-3 reveals a
rapid onset of acid-base imbalance in the internal environment. After
the CRRT treatment, the patient's serum sodium, potassium, electrolyte
ions, pH, as well as and heart, liver, and kidney function gradually
improved. Those improvements may be attributed to the removal of toxins,
inhibition of the patient's inflammatory response, and gradually
elimination of catecholamines, related substances, and their
metabolites.

\emph{CONCLUSION}

CRRT can be able to effectively eliminate catecholamines and their
byproducts from plasma as well as promote hemodynamic stability in
patients. It notably enhances heart, liver, and kidney functions,
reduces inflammatory cytokine levels; and extends therapeutic window for
patients.

\emph{REFERENCES}

1. Anna Riester DW, Marcus Quinkler,Urs D Lichtenauer,et al.
Life-threatening events in patients with pheochromocytoma. \emph{Eur J
Endocrinol} 2015;173(6):757-764.

2. B. C. Whitelaw JKP, O. G. Mustafa, K.-M. Schulte, et al.
Phaeochromocytoma crisis. \emph{Clinical Endocrinology} 2014(80):13-22.

3. Pisarska M, Pedziwiatr M, Budzynski A. Perioperative hemodynamic
instability in patients undergoing laparoscopic adrenalectomy for
pheochromocytoma. \emph{Gland Surg.} 2016;5(5):506-511.

4. Ankawi G NM, Zhang J, Breglia A, et al. Extracorporeal techniques for
the treatment of critically ill patients with sepsis beyond conventional
blood purification therapy: the promises and the pitfalls. \emph{Crit
Care.} 2018;22(1):262.

5. Al-Hwiesh A, Abdul-Rahman I, Finkelstein F, et al. Acute Kidney
Injury in Critically Ill Patients: A Prospective Randomized Study of
Tidal Peritoneal Dialysis Versus Continuous Renal Replacement
Therapy.\emph{Ther Apher Dial.} 2018;22(4):371-379.

Footnotes :Availability of data and material:The data and pictures
designed in this case report can be found in the information system of
the Third Affiliated Hospital of Sun Yat-Sen University and the Jinyu
Institutional Inspection Report.

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