Mechanical circulatory support such as extracorporeal membrane oxygenation is indicated in phaeochromocytoma crisis with sustained hypotension

Editor – Faloon and colleagues describe a 26-year-old man who developed phaeochromocytoma crisis following blunt abdominal trauma and attempted embolisation.¹ The patient had a phase of sustained hypotension giving rise to multi-organ dysfunction. Ischaemia of the colon was treated with emergency laparotomy without alpha blockade. Emergency adrenalectomy was performed intraoperatively for a ruptured phaeochromocytoma and retroperitoneal haemorrhage. It is to the credit of the team that this patient survived the episode despite the high mortality associated with this condition.²

We suggest that there are two additional learning points from this case.

Firstly, phaeochromocytoma crisis with sustained hypotension is notoriously difficult to manage and there is normally a significant component of myocardial dysfunction due to catecholamine toxicity. An effective treatment (along with aggressive volume replacement) is some form of mechanical circulatory support such as cardiopulmonary bypass or veno-arterial extracorporeal membrane oxygenation.^3,4 The use of this type of circulatory support is strongly associated with improved survival in hypotensive phaeochromocytoma crisis.² If required, urgent surgery can be performed whilst on mechanical support.⁵

Secondly, the authors correctly point out that intravenous alpha blockade (phentolamine and phenoxybenzamine) is currently difficult to access in UK. In preference to using no alpha blocking agents, clinicians who find themselves in these circumstances should consider using intravenous magnesium for medical stabilisation.^2,6 There is an evidence base for intravenous magnesium^7,8 as an alternative to alpha blockade and importantly the drug is familiar to many intensivists due to its critical role in eclampsia treatment.