A 55-year-old female adult, weighing 60 kg, presented with increased frequency and burning micturition, diagnosed with growth in bladder of 1.6 × 1.9 × 2.9 cm and She was posted for transurethral resection as ASA grade 1 patient.
Baseline parameters were recorded as heart rate (HR)-84/min, blood pressure (BP)-147/98 mmHg, and saturation (SpO2)-97% on room air. Spinal anesthesia was given using 26-G Quincke’s spinal needle with 3 mL of hyperbaric bupivacaine and sensory level of T8 was achieved. Three minutes after the subarachnoid block (SAB) a fall in BP was noted to reach 90/50 mmHg with for which she was given 3 mg of inj. ephedrine. BP came to 124/88 mmHg. Surgery was started and HR dipped from 68 to 55/min with a continuous increase of BP to 178/112 to 234/127 to 264/190 mmHg within a period of 5 min. Coincidentally, patient complained of severe headache, nausea, and respiratory distress. HR increased to 134/min with ventricular ectopics. Inj. lignocaine (1.5 mg/kg) was given but ectopics did not settle. She landed in ventricular tachycardia (VT) which resolved spontaneously.
The patient threw convulsions involving face and upper limbs and was immediately taken on bag and mask with 100% O2, airway was secured with cuffed ETT of internal diameter 7.5 mm. The whole event lasted for around 15 min, after which BP came back to 152/90 mmHg. The surgery was abandoned. She was successfully extubated with an HR-86/min, BP-136/88 mmHg and monitored in the postoperative area for 2 h.
Considering the differentials, after SAB, the first drop in BP was thought to be due to sympathectomy and thus ephedrine was administered. The reason for bradycardia which occurred next, was thought to have happened due to high spinal. However, a constant rise in BP excluded it. Focusing on the symptoms, it could have been due to thyroid storm but there was no rise in temperature and patient was not on any medications for the same. Next, we thought it could be carcinoid syndrome, but there was no evidence of bronchoconstriction. The moment shearing with cystoscope was done, the possible upsurge in catecholamine release, resulted in hemodynamic instability, seizure, ventricular ectopics, which after being metabolized by Catechol-O-methyltransferase within few minutes were reversed.
About 10%–15% of all the pheochromocytomas are extra adrenal in adults, extremely rare (0.06%) in urinary bladder, mostly seen in the trigone. 17% of them are seen to be asymptomatic. Increase in excitability of neurons by norepinephrine can lead to seizures. Mostly, they are seen in middle aged more common being in women.
Preoperative diagnosis can be reached at, by symptoms, presence of metanephrines in urine, radiological evidence of tumor on computed tomography/magnetic resonance imaging and metaiodobenzylguanidine scan. The histopathological section [Figure 1] is a confirmatory test where the chief cells have immunoreactivity to CD56, chromogranin A, and synaptophysin.
The time span in which the hemodynamics change is a matter of few minutes but it is lethal. Awareness and anticipation along with being prepared with the required drugs is a must to avoid catastrophic events.
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1. Sharma PK, Sharma P, Saraswat B Extraadrenal pheochromocytoma of urinary bladder Indian J Surg 2008 70 188 91
2. Leestma JE, Price EB Paraganglioma of the urinary bladder Cancer 1971 28 1063 73
3. Ansari MS, Goel A, Goel S, Durairajan LN, Seth A Malignant paraganglioma of the urinary bladder A case report. Int Urol Nephrol 2001 33 343 5
4. Piédrola G, López E, Rueda MD, López R, Serrano J, Sancho M Malignant pheochromocytoma of the bladder:Current controversies Eur Urol 1997 31 122 5
5. Fitzgerald P Is elevated norepinephrine an etiological factor in some cases of epilepsy? Seizure 2010 19 311 8