We experienced a hypertensive attack just immediately after bolus administration of dexamethasone during induction of general anesthesia in a patient with diagnosed pheochromocytoma. Anesthetic management for patients with pheochromocytoma requires attention to hypertensive attacks, and several drugs that cause hypertensive attacks are already known. However, there have been no reports of hypertensive attacks with dexamethasone administered to prevent PONV. Dexamethasone used for preventing PONV is not an essential agent in anesthetic management, and we should avoid using dexamethasone in patients with pheochromocytoma if it has the potential to produce a hypertensive crisis.

Several medications commonly used in anesthesia should be avoided or used cautiously in patients with pheochromocytoma. Although dexamethasone is listed in a review article as an alert [1], limited reports are available on the use of dexamethasone under general anesthesia. In this case, we thought that this hypertensive attack was related to dexamethasone since the attack occurred immediately after dexamethasone administration in the patient who had received adequate antihypertensive control with doxazosin and for whom the invasive procedures for tracheal intubation had not been performed until then. Furthermore, we took the utmost care to prevent hypertensive attacks in this pheochromocytoma patient during induction of anesthesia and used sufficient anesthetic induction drugs and narcotic analgesics to prevent hypertension during tracheal intubation. When the hypertensive attack occurred, the end-tidal concentration of sevoflurane was 1.5% and the estimated blood concentrations of fentanyl and remifentanil were 6.8 ng/ml and 2.2 ng/ml, respectively, which was considered sufficient to suppress noxious stimuli by tracheal intubation and vascular pain due to rocuronium. With respect to the management of anesthesia, we should avoid drugs that induce sympathetic tone, catecholamine release, and histamine release; however, rocuronium does not cause autonomic effects or histamine release [2].

Due to the rarity of pheochromocytoma, most data on anesthetic management and perioperative outcomes have been reported in small case series. In the past 11 case reports [3], as mentioned, it took several hours from glucocorticoid administration to the onset of side effects, such as hypertension, abdominal pain, and acute coronary syndrome in patients. None of these events occurred during general anesthesia. In terms of glucocorticoid potency, 6.6 mg of dexamethasone was relatively high. In two cases in which glucocorticoids of equivalent or higher potency were used, it took several hours or more for the onset of attacks.

Whether the hypertensive attack is specific to our patient or not is controversial. MEN type 2 patients, due to higher phenylethanolamine-N-methyltransferase and tyrosine hydroxylase expression, have an adrenergic phenotype with higher rates of catecholamine biosynthesis [4]. Our patient is highly suspected to have a MEN2-related gene based on her symptoms and findings (thyroid medullary carcinoma and family history). Hence, MEN type 2 patients, like in our case, may be a group of patients who are prone to a hypertensive crisis even with appropriate antihypertensive treatment.

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