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 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 114-115

Block: Component of a multimodal approach to taming the stress response in pheochromocytoma resection


1 Department of Anaesthesiology and Critical Care, Command Hospital (SC), Pune, Maharashtra, India
2 Department of Anaesthesiology and Critical Care, Armed forces Medical College, Pune, Maharashtra, India

Date of Web Publication25-Aug-2022

Correspondence Address:
Prof. Shalendra Singh
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_98_21

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How to cite this article:
Hooda B, Singh S, Dwivedi D, Goyal R. Block: Component of a multimodal approach to taming the stress response in pheochromocytoma resection. Indian J Pain 2022;36:114-5

How to cite this URL:
Hooda B, Singh S, Dwivedi D, Goyal R. Block: Component of a multimodal approach to taming the stress response in pheochromocytoma resection. Indian J Pain [serial online] 2022 [cited 2022 Sep 29];36:114-5. Available from: https://www.indianjpain.org/text.asp?2022/36/2/114/354726



Sir,

Resection of pheochromocytoma has great potential for intraoperative hemodynamic swings. Targeting a multimodal approach to counter catecholamine surge is the goal of anesthesia. Taking a cue from the vast application of transversus abdominis plane block (TAP) in abdominal and surgeries, we hypothesized that utilizing preemptive TAP block would not only provide postoperative analgesia in laparoscopic adrenalectomy but would also suppress the stress response and provide intraoperative analgesia reducing the requirement of anesthetics and opioids.[1]

A 58-year-old female was diagnosed with noradrenaline-secreting incidentaloma of the right adrenal. Complete endocrine workup and optimization with an alpha-blocker (prazosin 5 mg PO q12h) were instituted. After the optimization of blood pressure (BP), the patient was planned for laparoscopic adrenalectomy. Prazosin was continued, and lorazepam 2 mg per orally was given on the preoperative evening to allay anxiety along with overnight intravenous hydration. In the operation theater, after attaching standard monitors, dexmedetomidine 1 μg/kg was infused as a bolus over 10 min and the left radial artery was cannulated under local anesthesia with a 20 G cannula for the beat-to-beat monitoring of the BP at induction and thereof. Standard anesthetic technique was employed and right-sided TAP block was administered under ultrasound guidance by injecting 30 ml of 0.25% bupivacaine in the fascial plane. Baseline dexmedetomidine infusion was continued at the rate of 0.2 μg/kg/min, and anesthesia was maintained with sevoflurane in the oxygen-air mixture. The stress response at laryngoscopy was completely blunted by the combination of dexmedetomidine and fentanyl. At insertion of laparoscopic ports and CO2 insufflation, the change in the heart rate or BP was within 10% of baseline values and subsequently hemodynamics remained stable throughout the surgery. Postoperative analgesia was provided with patient-controlled analgesia with fentanyl (25 μg bolus with lockout 15 min and maximal 3 boluses/h) and acetaminophen 1000 mg q8h. She made an uneventful recovery and was discharged on the 5th postoperative day.

Hemodynamic instability is the most common adverse event in patients undergoing laparoscopic adrenalectomy and can potentially be a harbinger of major adverse events.[2]

TAP block as a means of reducing the stress response and postoperative analgesia is now common place in laparoscopic abdominal surgeries; employing this technique preoperatively in laparoscopic adrenalectomy remains elusive.[3] In addition, studies have suggested TAP block in laparoscopic surgery may modulate the surgical stress response.[4] A study employing dexmedetomidine with 60 ml of 0.2% ropivacaine in four-quadrant TAP block in laparoscopic gynecologic surgery and noted a similar statistically significant reduction in serum cortisol, norepinephrine, epinephrine, interleukin-6, blood glucose, and hemodynamic in a dose-dependent manner (P < 0.05) accompanied by decreased intraoperative anesthetic and opioid consumption (P < 0.05).[5]

We employed the right TAP block with 30 ml of 0.25% of bupivacaine with intravenous dexmedetomidine infusion before the incision and found better hemodynamic stability obviating the need for vasodilators to control hypertensive surges and reduced intraoperative anesthetic and postoperative opioid requirements.

Preemptive TAP block may be employed as a component of a multimodal approach to modulate the catecholamine surges and hemodynamic stability during laparoscopic adrenalectomy for pheochromocytoma management while providing postoperative analgesia and reducing opioid requirements.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Paul D, Kulkarni SN, Gupta N, Singh T, Dwivedi D, Singh S. Comparison of postoperative analgesic effect of transversus abdominis plane block versus direct wound infiltration with local anesthetic for lower segment cesarean section. J Mar Med Soc 2020;22:170-4.  Back to cited text no. 1
  [Full text]  
2.
Plouin PF, Duclos JM, Soppelsa F, Boublil G, Chatellier G. Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: Analysis of 165 operations at a single center. J Clin Endocrinol Metab 2001;86:1480-6.  Back to cited text no. 2
    
3.
Sharma RS, Agha M, Vyas R, Bhatia P, Sharma A. Prolonged analgesic effect of ultrasound-guided bilateral transversus abdominis plane block in pediatric patients. Indian J Pain 2020;34:47-9.  Back to cited text no. 3
  [Full text]  
4.
Karnik PP, Dave NM, Shah HB, Kulkarni K. Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries. Indian J Anaesth 2019;63:356-60.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Qin Z, Xiang C, Li H, Liu T, Zhan L, Xia Z, et al. The impact of dexmedetomidine added to ropivicaine for transversus abdominis plane block on stress response in laparoscopic surgery: A randomized controlled trial. BMC Anesthesiol 2019;19:181.  Back to cited text no. 5
    




 

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