Anesthetic management of a patient with pheochromocytoma and end-stage renal disease

We experienced anesthesia of a patient with pheochromocytoma on chronic hemodialysis who developed severe hypotension resistant to vasopressors after induction of general anesthesia. She was presented for spine surgery for destructive arthropathy of the cervical spine. Doxazosin up to 0.5 mg · day^-1 was administered for five days preoperatively for alpha-adrenergic blokade and regular hemodialysis was continued until the day before surgery without change in dry body weight. Blood pressure (BP) was within normal limits preoperatively. After induction of anesthesia with propofol and fentanyl, the patient developed hypotension with systolic BP of 60 mmHg which was resistant to vasopressor treatment with phenylephrine and ephedrine. After 45 minutes of volume replacement and commencement of dopamine and norepinephrine administration via a central venous catheter, BP recovered, and the surgery proceeded without further incident. Hypertension due to pheochromocytoma can be masked by excessive reduction of intravascular volume by preoperative hemodialysis. In a hemodialysed patient harboring pheochromocytoma who undergoes a surgical procedure unrelated to adrenalectomy, preoperative alpha-adrenergic blockade and subsequent intravascular volume expansion by increasing dry weight is required to avoid severe intraoperative hypotension, as for the case of adrenalectomy in the same situation.