A case presentation of 9 years old child diagnosed with Phenochromocytoma.

1. Management of hypertension crisis
( Pheochromocytoma ) in PICU
CASE PRESENTATION
GHADA EISSA ALMUWALLAD, RN, BSN
NURSING RESIDENCY TRANSITION TO
PRACTICE PROGRAM (PICU)

2. Outlines
•Biographical Data.
•Case Report & Past Medical- Surgical History.
•Physical Assessment.
•Medical Treatment.
•Nursing Care Plan.
•Patient & Family Teaching.
•Alternative Treatment.
•Conclusion.

3. Biographical Data
9 YearsAge
MaleGender
Al-MadinahFrom
21.6 kgWeight
118 cmHeight
NKAAllergy
StandardPrecaution
Full codeCode status

4. Case Report
Past Medical –Surgical
History
Family-
social History
Al-Madinah
26/December/2018
To 1 north
Endocrine
Suspect case of
“Pheochromocytoma
Chief Complaints
PRRT 27/December2018 due to
hypertension 225/140mmHg.
No medical – surgical history.
No history of inherited disorder.
Child living with their parents, with
moderate socioeconomic status.
(www.heart.org, 2017)

5. Introduction
(‫ا‬َّ‫ن‬ِ‫إ‬ٍ‫ر‬َ‫د‬َ‫ق‬ِ‫ب‬ ُ‫اه‬َ‫ن‬ْ‫ق‬َ‫ل‬َ‫خ‬ ٍ‫ء‬
ْ
‫ي‬ َ‫ش‬ َّ‫ل‬ُ‫ك‬[ )‫القمر‬:49]
(Indeed, all things We created with predestination) [Surah Al-Qamar [54:49] ]

6. Definition
• Pheochromocytoma is a rare cancer that originates
in neural crest cell in the (center medulla) of the
adrenal glands.
(The Cancer Genome Atlas - National Cancer Institute, 2017)
(Farrugia et al., 2017) & (MD Anderson Cancer Center, 2013)

8. Clinical manifestations
•High blood pressure(hypertension).
•Fatigue.
•Muscle weakness or spasms.
•Weight gain or loss.
•Insomnia or other sleep disorders.
•Low potassium levels.
•Headache.
• Rapid or irregular heartbeats.
• Feelings of anxiety, panic, fear.
• Pallor (paleness).
• Dizziness/lightheadedness with standing.
• Tremor.
• Sweating.
(The Cancer Genome Atlas - National Cancer Institute, 2017)

9. Statistic
•Each year, between 2 and 8 people per million worldwide are diagnosed with
paraganglioma and pheochromocytoma.
•Ten percent of all cases occur in children.
In both adults and children, pheochromocytoma is more common than paraganglioma.
•Approximately 90 percent of pheochromocytoma are benign
(The Cancer Genome Atlas - National Cancer Institute, 2017)

10. Physical Assessment
Neurological system Cardiovascular system
• Glasgow Coma Score:
15/15
• Pupil reaction:
Bilateral reactive, regular
, brisk 3 cm
• Headache
• ECG Rhythm : Sinus Tachycardia
• Heart Rate : 140 b/min.
• Blood Pressure : 225/140 mmHg
• Map : 147 mmHg
• Heart Sounds : S1S2
• Neck Veins: Flat
• Pulses: All Strong
• Peripheral Temperature: Warm
• Capillary Refill: Less Than 3
Second
• Palpitation

11. Respiratory system
• Respiratory rate: 44 bpm
• Oxygen source: nasal
cannula.
• Oxygen flow rate : 1L
• Oxygen saturation:100%
• ABG:
PH: 7.41
PO2: 74.6
PCO2 : 35
HCO3: 21.8
Gastro-intestinal system
• Diet: NPO
• Blood sugar: 5 mmol/L
• Abdomen palpation : soft
• Bowel sounds: Present
• Nausea
Physical Assessment

12. Integumentary system
• Temperature: 37.1 C
• Sweating
Renal system
• Voiding no difficulty
Psychosocial Pain score
• Behavior: anxious • Wong-baker face pain scale
• Pain score : 6
Eyes
• Blurred vision
Physical Assessment

13. Diagnostictest

14. Laboratory
Test Normal values Result
Plasma fractionated - Normetanephrine >180pg/mL 17400pg/mL
Plasma fractionated -Metanephrine >90 pg/mL 100 pg/ml
24-hour urinary -Normetanephrine
0 – 3.43 umol/Day
151.46 umol/Day
24-hour urinary -Metanephrine
0- 2.06umol/Day
11.61 umol/Day
Urea 1.2 – 3 mmol/l 13.8 mmol/l
Creatinine 34 – 65 umol/l 33 mmol/l
K 3.5-5 mmol/L 2.4 mmol/l
Na 135-145 mmol/l 138 mmol/l
27/12/2018

15. Diagnostictest
Abdomen ultrasound:
There is a heterogeneous pelvic mass adjacent to the urinary bladder that measures up to 5.5 cm. Recommend
MRI for further evaluation.
Abdomen magnetic resonance imaging :
There is a left pelvic presacral mass that measures up to 5.4 cm, likely represents adrenal Pheochromocytomas;
other less likely differential is metastasis.
27/12/2018
30/12/2018

16. Pharmacological
ConsiderationIndicationDoseMedication
Pain assessment.
Respiratory assessment.
Control pain1 mg , IV, prnMorphine
Monitor serum potassium before and
periodically during therapy
Symptoms of hyperkalemia .
Replacement15 mmol, oral, dailyPotassium-chloride
Monitor BP- HR closely. Hypotension
is a common side effect that may
require intervention.
Reduces blood pressure0.13mg, Oral,q6rCentrally acting alpha-
agonist Clonidine
Monitor BP- HR closely. Hypotension
is a common side effect that may
require intervention.
Control blood pressure15mg, Oral, q8hPropranolol
Medical Treatment

17. ConsiderationIndicationRate / DoseInfusion
Measure blood sugar.
Na serum level.
Maintenance50 ml/hr.Dextrose 5% and 0.45% NaCl
1000 mL
Monitor BP- HR closely.
Hypotension is a common
side effect that may require
intervention.
Reduces blood pressure and
heart rate
4 mcg/kg/min, IVNonselective α-adrenergic
antagonist Phentolamine
Overdosage of nitroprusside.
Administration consideration.
Reduces blood pressure
and heart rate
3 mcg/kg/min, IVNitropress , Nitroprusside
Medical Treatment Pharmacological

18. Nursing Care Plan
Assessment Diagnosis Plan Nursing Interventions Outcomes
Subjective
cues:
Headache
Blurred vision
Pain
Objective cues:
High blood
pressure
225/140 mmHg
Decreased
cardiac output
related to
increased
peripheral
vascular
resistance
secondary to
hypertension as
evidence by BP
225/140,.
patient
complaining of
blurred vision,
and headache.
After
intervention the
patient will:
• Maintain BP
within
individually
acceptable
range.
• Verbalize an
absent in a
headache
and blurred
vision within
12 hours.
1. Non- pharmacological:
Dietary management.
2. Pharmacological:
• Administer centrally acting alpha-agonist as
prescribed Clonidine.
• Administer nonselective α-adrenergic
antagonist as prescribed Phentolamine.
• Administer Vasodilator Nitropress as
prescribed Nitroprusside.
• Assessment
after
medication
administion
will reveal
normal Blood
pressure.
• Verbalization
absent of
headache and
blurred vision
within 12
hours.

19. Nursing Care Plan
Assessment Diagnosis Plan Nursing Interventions Outcomes
Subjective cues:
Palpitation
Nausea
Objective cues:
Diaphoresis
Anxiety secondary
to hormonal level
change as evidence
by diaphoresis &
patient verbalized
of experience
palpitation
& nausea.
After intervention the
patient will:
• Appear relaxed and
report anxiety is
reduced to a
manageable level.
• Verbalize awareness of
feelings of anxiety.
• Identify health ways to
deal with and express
anxiety.
1. Non- pharmacological:
Promote comfortable environment
by ( spiritual care, relaxation,
position, light, noisy etc.).
2. Pharmacological:
Administer antihypertension
medication .
Re- assess after
30 minutes, the
patient will
reports relief of
anxiety and
discomfort.

20. Nursing Care Plan
Assessment Diagnosis Plan Nursing Interventions Outcomes
Subjective
cues:
Blurred vision
Objective cues:
Blood Presser :
225/140
mmHg
Risk for fall secondary
to visual difficulties .
After intervention the
patient will:
• Patient will not
sustain fall.
• Patient will
demonstrate
prevention measures.
• Patient and caregiver
will implement
strategies to increase
safety and prevent
fall.
1. Using standard assessment tools,
the level of risk and fall
precautions can be determined.
2. Assess the patient’s environment
factors known to increase fall
risk such as unfamiliar setting,
inadequate lighting, wet
surfaces, and objects on the
floor than adjust it .
Patient and
caregiver prevent
any falling event .

21. Patient family education
1
2
3
4

22. Alternative treatment
• There are two types of surgical
intervention to remove the adrenal gland
tumor
(Endocrinediseases.org, 2017) & (Baudin et al., 2014)
• Cytotoxic chemotherapy and
palliative are the first intervention for
malignant cell tumors.

23. Evidence base practice
•The use of metoclopramide is contraindicated in patients with pheochromocytoma. In a study involving patients
with essential hypertension, intravenously administered metoclopramide was shown to induce the release of
catecholamines. Hypertensive crises may occur in patients with pheochromocytoma due to induction of
catecholamine release from the tumor.
Metoclopramide ↔ pheochromocytoma

24. Conclusion

26. References
•Baudin, E., Habra, M., Deschamps, F., Cote, G., Dumont, F., Cabanillas, M., Arfi-Roufe, J., Berdelou, A., Moon, B., Al
Ghuzlan, A., Patel, S., Leboulleux, S. and Jimenez, C. (2014). THERAPY OF ENDOCRINE DISEASE: Treatment of
malignant pheochromocytoma and paraganglioma. European Journal of Endocrinology, 171(3), pp.R111-R122.
•Bashir, O. (n.d.). Adrenal gland | Radiology Reference Article | Radiopaedia.org. [online] Radiopaedia.org. Available at:
https://radiopaedia.org/articles/adrenal-gland [Accessed 16 Mar. 2019].
•Endocrinediseases.org. (2017). Treatment of Pheochromocytoma. [online] Available at:
http://endocrinediseases.org/adrenal/pheochromocytoma_treatment.shtml [Accessed 16 Mar. 2019].
•Farrugia, F., Martikos, G., Tzanetis, P., Charalampopoulos, A., Misiakos, E., Zavras, N. and Sotiropoulos, D. (2017).
Pheochromocytoma, diagnosis and treatment: Review of the literature. Endocrine Regulations, 51(3), pp.168-181

27. •The Cancer Genome Atlas - National Cancer Institute. (2017). Paraganglioma & Pheochromocytoma. [online] Available at:
https://cancergenome.nih.gov/cancersselected/ParagangliomaPheochromocytoma [Accessed 4 Mar. 2019].
•NORD (National Organization for Rare Disorders). (2019). Pheochromocytoma - NORD (National Organization for Rare
Disorders). [online] Available at: https://rarediseases.org/rare-diseases/pheochromocytoma/ [Accessed 11 Mar. 2019].
•MD Anderson Cancer Center. (n.d.). Adrenal Tumors. [online] Available https://www.mdanderson.org/cancer-types/adrenal-
tumors.html [Accessed 4 Mar. 2019].
•Ramachandran, R. and Rewari, V. (2016). Current perioperative management of pheochromocytomas. Indian Journal of Urology,
0(0), p.0.
•www.heart.org. (2017). Understanding Blood Pressure Readings. [online] Available at: https://www.heart.org/en/health-topics/high-
blood-pressure/understanding-blood-pressure-readings [Accessed 31 Mar. 2019].
References