Pheochromocytoma an Adrenaline Addict - A Case Report

Abstract

A 20-years-old female patient presented for pre-operative evaluation for excision of left sided adrenal tumour. She complained of intermittent abdominal pain, excessive sweating, episodic headache since 2 years and palpitations since 6 months. The patient was diagnosed with hypertension two years back and was started on Tabs. Prazosin 15 mg twice daily, Clonidine 100 mg thrice daily, Furosemide 40 mg daily. The patient's previous medical and surgical history was uneventful.On examination, height was 165 cms and weight 53 kgs. The ASA physical status classification was ASA 3. Mallampatti classification-1. The heart rate was regular, 140 per minute. Her blood pressure in supine position was -200/130 mm of Hg and standing-190/120 mm of Hg. Pulse rate was 140 bpm, regular in nature. Rest of the examination was unremarkable [Table/ Fig-1-4].Ophthalmology, Endocrinology and Cardiology opinions were taken. Increase in drug dosage, addition of β-blocker and Calcium Channel blocker was advised.By second visit, she was receiving tablets Clonidine 100 mg thrice daily, Prazosin 15 mg twice daily, Furosemide 40 mg once daily, Atenolol 50 mg twice daily, Nicardipine 20 mg twice daily and Alprazolam 0.5 mg once daily. Her B.P. was -150/110 mm of Hg in sitting and 150/100 mm of Hg in supine position with a pulse rate of 120 bpm.Patient was started on Tab. Lorazepam 3 days before surgery for anxiolysis. I.V fluid therapy with 1.5 litres of crystalloid/day was started 3 days prior to ensure hydration. All drugs were continued till day of surgery. Preoperative B.P in supine position was 120/98 mm of Hg, standing 80/40 mm of Hg with a pulse rate of 88 bpm.Patient was planned for combined General and epidural Anaesthesia.Two 18 G I.V. line secured. Two Ringer Lactate started. ECG, SpO2, NIBP, CVP and EtCO2 monitors were arranged. Epidural catheter was secured at T10-T11 level, a test dose of lignocaine 3 cc tried and a bolus of 0.5% bupivacaine 6 cc administered. CVP triple lumen 18G line was secured under asepsis. Blood pressure was monitored. Continuous ECG, PR, and EtCO2 monitoring was done. CVP and urine output were measured every half an hour. Patient was started on I.V. Vecuronium infusion of 3 mghr-1, epidural infusion of 0.125% bupivacaine with fentanyl 25 µg at 6ml/ hr and maintained throughout the duration of surgery. SNP infusion started at 0.5 µgkgmin-1 at incision and titrated according to B.P. with maximum dose at 1 µgkgmin-1. Propofol infusion started at 100mghr-1. Inj fentanyl 50 µg I.V. was repeated at 1.5 hr and 3 hrs. CVP was maintained around 10cms of H2O.Intraoperatively, vitals remained stable. After ligation of main adrenal vein, patient's B.P. and P.R. increased. Administered Esmolol bolus 5 mg which was repeated after 15 min, Esmolol infusion 50 µg/ kgmin-1 was started and tapered accordingly. Multiple draining veins were ligated. B.P. reduced, Esmolol infusion and SNP infusion were stopped.Patient received 10 crystalloids and 2 colloids over 4 hrs and sustained a blood loss of 400 ml. Urine output was 2500 ...