# Anesthetic Management of Metastatic Paraganglioma With Spinal Metastases in a Comorbid Cardiovascular Patient

## TL;DR

This paper discusses the anesthetic challenges and strategies for a patient with spinal metastatic paraganglioma and heart failure undergoing surgery.

## Contribution

The paper presents a case study highlighting anesthetic management strategies for a complex patient with metastatic paraganglioma and cardiovascular comorbidities.

## Key findings

- A combination of low-dose isoflurane, propofol, dexmedetomidine, and remifentanil was effective for anesthetic depth and neuromonitoring.
- Vasopressin was primarily used to manage hypotension due to high alpha-blockade.
- Aggressive volume resuscitation was necessary to address significant surgical bleeding.

## Abstract

Paragangliomas are rare neuroendocrine tumors characterized by the secretion of catecholamines. The primary treatment of these tumors consists of a period of medical optimization with oral alpha-blockade followed by surgical resection. Anesthetic management of these patients is challenging due to the potential for significant hemodynamic instability intraoperatively. This report outlines the anesthetic considerations of a patient undergoing multilevel spinal tumor resection of symptomatic metastatic paraganglioma. We present the case of a 55-year-old male patient with a history of heart failure with reduced ejection fraction (HFrEF) who underwent multilevel resection of metastatic paraganglioma of the spine. The patient was treated with one week of oral alpha-blockade preoperatively for uncontrolled hypertension. A combination of low-dose isoflurane, propofol, dexmedetomidine, and remifentanil was used to maintain adequate anesthetic depth while allowing for neuromonitoring. Due to the high level of alpha-blockade, anesthesia-induced hypotension was primarily managed with vasopressin. The intraoperative course was complicated by significant surgical bleeding, which was treated with aggressive volume resuscitation. In the event of hypertension or tachycardia, nicardipine, nitroglycerin, and esmolol were available, although their use was not required. Spinal tumor resection of metastatic paraganglioma requires a thoughtful anesthetic strategy and can be further complicated by patient comorbidities. These conditions require clinicians to thoroughly understand the disease and consider the mechanisms of action of common medications used in anesthesia practice to ensure patient safety.