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  1. #1
    Join Date
    Dec 2009

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    Question Interesting experience this week

    So I had a really great experience this week. We were doing a robot assisted lap cystectomy with urinary diversion for bladder cancer. Induced pt and placed in steep trendelenberg. Giving Neo and ephedrine for pressures in the toilet. We put in an a-line in pre-op b/c the patient was a vasculopath and already had a BKA. So we knew we might have bp problems. As soon as the surgeon got into the bladder the bp started to climb. We turned up the gas and gave fentanyl. bp continued to climb to 180's then 190s then 250 then 330/200 within 30 seconds. We started giving labetolol which really had no effect at all. Tried some esmolol and that seemed to help a little. We questioned the surgeon about the type of tumor this was and they said it was a transitional cell tumor. Questioned about possiblity of a pheo or norepi secreting carcinoid but they say no way. I've never seen b/p go up this fast or this high. We don't keep alpha blockers in the pyxis b/c I suggested this to the crna thinking could this be an undiagnosed pheo? We ended up pushing 200mcg of nitro at a time to get the pressures down into the 200's. We ended up getting them under control to the 140's systolic and kept a nitro drip going. 10 minutes later the blood pressure surges again into the 300's (while on the nitro gtt). We tell the surgeons "if you're not done soon with the robotics part we're just gonna have to go to open b/c the pt is not tolerating this". At this point his sats are starting to drop to 88 on 100% FiO2 and PIP are 56. We can't give Lasix b/c the ureters are already clamped. AFter the bladder is out the blood pressure trends down and we are fighting hypotension for the rest of the case. Giving epi right up to the end. So we wait until the ureters are unclamped, give Lasix and are able to extubate and the patient was neurologically intact upon emergence. 12 lead, labs, abg, the works in PACU. Seen patient next day and he's doing great.

    Go to clinicals yesterday and find out the it WAS a pheochromocytoma of the bladder. Pretty rare apparently. It was a great experience and I just thought I'd share. Anyone else have a good story about an undiagnosed pheo?
    Last edited by srna26; 09-24-2011 at 02:51 PM.

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