The haemodynamic instability score: Development and internal validation of a new rating method of intra-operative haemodynamic instability

Perioperative Management and Outcome of Catecholamine-Induced Takotsubo and Dilated Cardiomyopathy in Pheochromocytoma and Paraganglioma

OBJECTIVES

To outline and compare the clinical features, preoperative preparation, perioperative management, and outcome of Takotsubo cardiomyopathy (TCM) and dilated cardiomyopathy (DCM) associated with pheochromocytomas and paragangliomas (PPGLs).

DESIGN

A retrospective cohort study.

SETTING

A single tertiary hospital.

PARTICIPANTS

All patients scheduled for elective surgery of PPGL resection with TCM and DCM between March 2005 and June 2023 were enrolled.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This study enrolled 29 patients: 20 patients were in the TCM group and 9 patients were in the DCM group. The tumor size of the DCM group was bigger and the level of 24-hour urine norepinephrine was higher than those in the TCM group. After the preoperative medication preparation (111 median days) and anti-heart failure treatment (if necessary), the mean preoperative ejection fraction in the TCM group was significantly higher than that in the DCM group (66.8% ± 4.4% v 48.8% ± 7.8%, p<0.001), both elevated compared to ejection fraction at presentation (p<0.001). The intraoperative hemodynamic instability score was rather high in PPGL-TCM and PPGL-DCM patients (84.6 points), as well as in the hemodynamic variables section (13.7 points). Patients with DCM were more prone to present hemodynamic disturbances and to require a lower volume of fluids but a higher infusion of vasoactive agents than patients with TCM. The incidence of complications was 6.9% and there was no perioperative mortality.

CONCLUSIONS

Following the preoperative medication preparation and anti-heart failure treatment, patients with TCM had better left ventricular recovery before surgery and fewer cardiovascular risks compared to patients with DCM. Optimal perioperative management and individualized anesthetic strategies are essential for this unique patient population.

Multicenter observational study of patients who underwent cardiac surgery and were hospitalized in an intensive care unit (BraSIS 2): study protocol and statistical analysis plan

BACKGROUND

The perioperative management of patients undergoing cardiac surgery is highly complex and involves numerous factors. There is a strong association between cardiac surgery and perioperative complications. The Brazilian Surgical Identification Study (BraSIS 2) aims to assess the incidence of death and early postoperative complications, identify potential risk factors, and examine both the demographic characteristics of patients and the epidemiology of cardiovascular procedures.

METHODS AND ANALYSIS

BraSIS 2 is a multicenter observational study of patients who undergo cardiac surgery and who are admitted to the intensive care unit. The primary objective is to describe the risk factors and incidence of mortality or severe postoperative complications occurring within the first 3 postoperative days of cardiac surgery or until intensive care unit discharge (whichever event occurs first). Severe postoperative complications include acute myocardial infarction, acute respiratory distress syndrome, cardiorespiratory arrest with return of spontaneous circulation, Kidney Disease Improving Global Outcomes stage ≥ 2, a new surgical approach being conducted in an unscheduled event of urgency or emergency, renal replacement therapy, septic shock, severe bleeding, severe hemodynamic instability, stroke, unplanned reintubation, and unplanned use of a circulatory assistance device. The secondary outcomes include the evaluation of patient characteristics and descriptions of the performed surgeries and administered anesthesia. This study will also assess intraoperative and postoperative complications, as well as risk factors associated with postoperative complications and mortality. We expect to recruit 500 patients from at least 10 Brazilian intensive care units. Trial registration: NCT06154473; partial results.

Short-acting urapidil compared to long-acting phenoxybenzamine in the management of pheochromocytoma

PURPOSE

In patients with pheochromocytoma current guidelines recommend preoperative alpha-adrenoceptor blockade with selective or nonselective antagonists for at least 7-14 days. To date, no information exists about orally administered urapidil retard, a short-acting selective antagonist.

METHODS

The medical records of consecutive patients with pheochromocytoma between 2010 and 2023 were reviewed. Patients received phenoxybenzamine between 2010 and 2017, intravenous urapidil was given between 2017 and 2019. Orally administered urapidil retard has been used from 2019 until present.

RESULTS

Forty-nine patients with pheochromocytomas were included. Twenty-six patients received orally administered long-acting phenoxybenzamine and 23 patients were pretreated with short-acting intravenous (n = 8) or orally administered urapidil (n = 15). Treatment prior to surgery was significantly shorter with intravenously (3 days (IQR, 3-4), p = 0.015) or orally administered urapidil (2 days (IQR 2-3), p = 0.003) compared to phenoxybenzamine (7 days (IQR, 4-10)). Side effects were more often in the phenoxybenzamine group (17/26 vs 6/23, p = 0.02). The modified hemodynamic instability (HI) score was low and there was no significant difference between patients treated with phenoxybenzamine and those treated with intravenous or oral urapidil (29 (IQR 18.5-38); 26 (IQR 18-42); 31 (IQR 15-36) ns). No 30-day postoperative mortality or cardiovascular complications occurred in any of the three groups. The postoperative hospital stay was significantly shorter in the orally administered urapidil group compared to the phenoxybenzamine group (3 days (IQR 3-5)) vs 4 days (IQR 4-5)), p = 0.04).

CONCLUSION

Oral pretreatment with urapidil retard is well tolerated for patients with pheochromocytoma, enabling a safe intra- and postoperative course.

The use of the surgical pleth index to guide anaesthesia in gastroenterological surgery: a randomised controlled study

The measurement of nociception and the optimisation of intraoperative antinociceptive medication could potentially improve the conduct of anaesthesia, especially in the older population. The Surgical Pleth Index (SPI) is one of the monitoring methods presently used for the detection of nociceptive stimulus. Eighty patients aged 50 years and older who were scheduled to undergo major abdominal surgery were randomised and divided into a study group and a control group. In the study group, the SPI was used to guide the administration of remifentanil during surgery. In the control group, the SPI value was concealed, and remifentanil administration was based on the clinical evaluation of the attending anaesthesiologist. The primary endpoint of this study was intraoperative remifentanil consumption. In addition, we compared the durations of intraoperative hypotension and hypertension. No difference in intraoperative remifentanil consumption (4.5 µg kg- 1h- 1 vs. 5.6 µg kg- 1h- 1, p = 0.14) was found. Furthermore, there was no difference in the proportion of hypotensive time (mean arterial pressure, MAP < 65) (3.7% vs. 1.6%, p = 0.40). However, in the subgroup of patients who underwent operation with invasive blood pressure monitoring, there was less severe hypotension (MAP < 55) (0.3% vs. 0.0%, p = 0.02) and intermediate hypotension (MAP < 65) (10.2% vs. 2.6%, p = 0.07) in the treatment group, even though remifentanil consumption was higher (3.5 µg kg- 1h- 1 vs. 5.1 µg kg- 1h- 1p = 0.03). The use of SPI guidance for the administration of remifentanil during surgery did not help to reduce the remifentanil consumption. However, the results from invasively monitored study group suggest more timely administered opioid when SPI was used.

Intraoperative hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma without preoperative medical preparation compared with nonsecreting tumor

BACKGROUND

Control of hemodynamic features during adrenalectomy for pheochromocytoma is recommended to minimize perioperative cardiovascular complications. However, episodes of intraoperative hemodynamic instability have been observed during adrenalectomies with other indications than pheochromocytoma. The objective of this study was to compare the hemodynamic instability score assessed during unilateral adrenalectomy for pheochromocytoma without preoperative medical preparation to hemodynamic instability score in nonsecreting tumor.

METHODS

This was an observational study with prospective intraoperative hemodynamic data collection (every 20 seconds) and retrospective analysis.

RESULTS

During the study period, 60 consecutive patients (30 pheochromocytomas vs 30 nonsecreting tumors) were included with a median number of data collections during total procedure time of 318 (interquartile range, 257-388). Mean cumulative intraoperative time outside the target blood pressure range expressed as a percentage of total procedure time was 13.3% vs 6.8% for systolic blood pressure >160 mm Hg (P = .01) and 2.4% vs 2.8% for mean arterial pressure <60 mm Hg (P = ns), respectively. The median hemodynamic instability score during total procedure time was 33 (interquartile range, 27-43) and 20 (interquartile range, 11-26) in the pheochromocytoma and nonsecreting tumor group, respectively (P < .01). Hemodynamic instability score were similar in patients with compared with without long-term antihypertensive treatment in each patient group (P = ns). The mean length of hospital stay was 2.0 ± 1.5 days, and 30-day morbidity rate was 6.6% (4/60) with no significant difference observed between both groups.

CONCLUSION

Although intraoperative hemodynamic instability remains greater in the pheochromocytoma group without preoperative medical preparation, both groups have similar hypotensive episodes. These data highlight the need to better understand the role of preoperative medical preparation in pheochromocytoma patients.

Postoperative arterial hypotension: the unnoticed enemy

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

Influence of duration of preoperative treatment with phenoxybenzamine and secretory phenotypes on perioperative hemodynamics and postoperative outcomes in pheochromocytoma and paraganglioma

Objectives

Resection of pheochromocytoma and paraganglioma (PPGL) carries risks with perioperative hemodynamic instability. Phenoxybenzamine (PXB) is a commonly used α-blockade to prevent it. It is unclear whether lengthening the preoperative duration of PXB is better for hemodynamic stability and postoperative outcomes. Furthermore, different types of catecholamines have varying effects on perioperative hemodynamics. Thus, our study aimed to investigate the impact of the duration of preoperative preparation with PXB and secretory phenotypes of the patients on intraoperative hemodynamic stability and postoperative complications in PPGL.

Methods

Between Dec 2014 and Jan 2022, 166 patients with PPGL were operated on by the same team at Sun Yat-sen Memorial Hospital. They were divided into group A(1-14d), Group B(15-21d), and Group C(>21d) based on the duration of management with PXB and into the adrenergic and the noradrenergic phenotype group based on secretory profiles. Data on intraoperative hemodynamics and postoperative outcomes were collected and compared among groups.

Results

A total of 96 patients occurred intraoperative hemodynamic instability, and 24 patients had 29 postoperative complications related to the surgery. Among the 145 patients treated with PXB, no significant differences were found in the cumulative time outside the target blood pressure(6.67%[0-17.16%] vs. 5.97%[0-23.08%] vs. 1.22%[0-17.27%], p=0.736) or in the median total HI-score(42.00[30.00-91.00] vs. 89.00[30.00-113.00] vs. 49.00[30.00-93.00], p=0.150) among group A(n=45), B(n=51) and C(n=49). Multivariate analysis demonstrated that the level of plasma-free metanephrine(MN) was an independent risk factor for intraoperative hemodynamic instability. And the median cumulative time outside of the target blood pressure in the adrenergic phenotype group was significantly greater than that in the noradrenergic phenotype group(8.17%[0-26.22%] vs. 1.86%[0-11.74%], p=0.029). However, the median total HI-score(99.50[85.00-113.25] vs. 90.00[78.00-105.00], p=0.570) and postoperative outcomes showed no differences between the two groups.

Conclusions

A preoperative duration of nearly 14 days with PXB is sufficient for ensuring intraoperative hemodynamic stability in PPGL. And lengthening the preparation duration may not provide additional benefits in the era of widespread application and advanced techniques of laparoscopic surgery. Additionally, patients with the adrenergic phenotype are more prone to intraoperative hemodynamic instability than the noradrenergic phenotype. Thus, more attention should be given to the adrenergic phenotype during surgery.

Non-Selective Alpha-Blockers Provide More Stable Intraoperative Hemodynamic Control Compared with Selective Alpha1-Blockers in Patients with Pheochromocytoma and Paraganglioma: A Single-Center Retrospective Cohort Study with a Propensity Score-Matched Analysis from China

PURPOSE

Alpha-adrenergic blockers are used in the preoperative preparation of patients with pheochromocytomas and paragangliomas (PPGLs) despite the controversial on perioperative hemodynamics. We aimed to determine whether selective or non-selective α-adrenergic blockers can provide better efficacy on patients' intraoperative hemodynamics.

PATIENTS AND METHODS

This single-center retrospective study was conducted in 2507 adult patients undergoing PPGL resections, patients received alpha-adrenergic receptor blockers as a binary variable (selective or non-selective). Propensity score matching was performed and 201 patients were matched successfully.

RESULTS

A total of 201 patients with PPGL were included in this study. The HI score scores were higher in the selective group than in the non-selective group (60.5 [44.5-84.0] vs 49.0 [37.0-67.25], P=0.027), as well as in the hemodynamic variables section [14.0 [8.0-20.0] vs 10 [6.0-16.0], P=0.009). In terms of specific indicators for each component, the lowest MAP in the selective group (55±10 mmHg vs 59±8 mmHg, P=0.038), the time to MAP below 60 mmHg (0.011% vs 0.022%, P=0.033) and the use of other vasoconstrictors (56.5% vs 35.5%, P=0.019) were significantly lower than in the non-selective group. Among the secondary outcome indicators, the incidence of intraoperative maximum SBP was significantly higher in the selective group than in the non-selective group (32.3% vs 11.3%, P=0.005). There were no significant differences in postoperative outcome indicators between the two groups.

CONCLUSION

In patients with PPGL, patients prepared preoperatively with non-selective alpha-blockers presented more stable hemodynamics intraoperatively compared to selective alpha1-blockers.

Effect of C-Clamp Application on Hemodynamic Instability in Polytrauma Victims with Pelvic Fracture

Background and Objectives: C-clamp application may reduce mortality in patients with unstable pelvic fractures and hemodynamic instability. Decreasing C-clamp use over the past decades may have resulted from concerns about its effectiveness and safety. The purpose of this study was to document effective hemodynamic stabilization after C-clamp application by means of vital parameters (primary outcome parameter), and the subsequent effect on metabolic indices and volume management (secondary outcome parameters). Materials and Methods: C-clamp application was performed between 2014 and 2021 for n = 13 patients (50 ± 18 years) with unstable pelvic fractures and hemodynamic instability. Vital parameters, metabolic indices, volume management, and the correlation of factors and potential changes were analyzed. Results: After C-clamp application, increases were measured in systolic blood pressure (+15 mmHg; p = 0.0284) and mean arterial pressure (+12 mmHg; p = 0.0157), and a reduction of volume requirements (p = 0.0266) and bolus vasoactive medication needs (p = 0.0081) were observed. The earlier C-clamp application was performed, the greater the effect (p < 0.05; r > 0.6). Heart rate, shock index, and end-tidal CO2 were not significantly altered. The extent of base deficit, hemoglobin, and lactate did not correlate with changes in vital parameters. Conclusions: In the majority of hemodynamically unstable trauma patients not responding to initial fluid resuscitation and severe pelvic fracture, early C-clamp application had an additive effect on hemodynamic stabilization and reduction in volume substitution. Based on these findings, there is still a rationale for considering early C-clamp stabilization in this group of severely injured patients.

Influence of Receptor Polymorphisms on the Response to α-Adrenergic Receptor Blockers in Pheochromocytoma Patients

Background: Presurgical treatment with an α-adrenergic receptor blocker is recommended to antagonize the catecholamine-induced α-adrenergic receptor mediated vasoconstriction in patients with pheochromocytoma or sympathetic paraganglioma (PPGL). There is, however, a considerable interindividual variation in the dose-response relationship regarding the magnitude of blood pressure reduction or the occurrence of side effects. We hypothesized that genetically determined differences in α-adrenergic receptor activity contribute to this variability in dose-response relationship. Methods: Thirty-one single-nucleotide polymorphisms (SNPs) of the α1A, α1B, α1D adrenoreceptor (ADRA1A, ADRA1B, ADRA1D) and α2A, α2B adrenoreceptor (ADRA2A, ADRA2B) genes were genotyped in a group of 116 participants of the PRESCRIPT study. Haplotypes were constructed after determining linkage disequilibrium blocks. Results: The ADRA1B SNP rs10515807 and the ADRA2A SNPs rs553668/rs521674 were associated with higher dosages of α-adrenergic receptor blocker (p < 0.05) and with a higher occurrence of side effects (rs10515807) (p = 0.005). Similar associations were found for haplotype block 6, which is predominantly defined by rs10515807. Conclusions: This study suggests that genetic variability of α-adrenergic receptor genes might be associated with the clinically observed variation in beneficial and adverse therapeutic drug responses to α-adrenergic receptor blockers. Further studies in larger cohorts are needed to confirm our observations.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study

BACKGROUND

Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma.

MATERIALS AND METHODS

This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed.

RESULTS

In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy.

CONCLUSIONS

The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

Risk Factors for Perioperative Hemodynamic Instability in Pheochromocytoma: A Systematic Review and Meta-Analysis

Objective: To evaluate the risk factors of perioperative hemodynamic instability in pheochromocytoma, we conducted a systematic search of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analysis. Methods: In April 2021, we systematically searched PubMed, the Cochrane library, and Scopus for relevant studies on the risk factors of perioperative hemodynamic instability of adrenalectomy in patients with pheochromocytoma, and we subjected the findings from those studies to formal meta-analysis. Results: Our systematic review identified 14 studies involving 1725 patients, of which nine studies with 967 patients were eligible for meta-analysis. The results of meta-analysis showed that tumor size (odds ratio (OR): 1.14 for each increased cm, 95% confidence interval (CI) 1.03–1.26, z = 2.57) and urinary norepinephrine (OR, 1.51: 95% CI 1.26–1.81; z = 4.50) were most closely associated with the occurrence of perioperative hemodynamic instability. Conclusion: These findings suggest that tumor size and urinary norepinephrine are important predictors and risk factors for perioperative hemodynamic instability in adrenalectomy for pheochromocytoma. Such findings may be of value to surgeons and anesthesiologists when considering or preparing for this procedure.

Perioperative hemodynamic instability in pheochromocytoma and sympathetic paraganglioma patients

For pheochromocytoma and sympathetic paraganglioma (PPGL), surgery can be used as a curative treatment; however, the life-threatening risk of perioperative hemodynamic instability (HI) presents challenges. This study aimed to analyze the incidence and predictive factors of perioperative HI. The electronic medical records of 114 consecutive patients who underwent surgery for PPGLs at our institution were retrospectively reviewed. HI was defined as one or more episodes of systolic blood pressure > 200 mmHg or mean blood pressure < 60 mmHg during surgery. The factors predictive of perioperative HI were determined using both univariate and multivariate analyses. Intraoperative HI occurred in 79 (69.3%) patients. In multivariate analysis, α-adrenergic receptor blocker duration (days) (odds ratio, 1.015; 95% confidence interval, 1.001–1.029) was a predictor for intraoperative HI. Postoperative hypotension occurred in 36 (31.6%) patients. Higher urine epinephrine levels, and greater preoperative highest heart rate (HR) were predictive factors for postoperative hypotension in PPGL patients. Caution should be taken in perioperative management for PPGL, especially with long duration of α-adrenergic receptor blocker use, higher urine epinephrine levels, and greater preoperative highest HR.

Preoperative Amlodipine Is Efficacious in Preventing Intraoperative HDI in Pheochromocytoma: Pilot RCT

CONTEXT

Preoperative blockade with α-blockers is recommended in patients with pheochromocytoma/paraganglioma (PPGL). The data on calcium channel blockade (CCB) in PPGL are scarce.

OBJECTIVE

We aimed to compare the efficacy of CCB and α-blockers on intraoperative hemodynamic instability (HDI) in PPGL.

METHODS

In the interim analysis of this monocentric, pilot, open-label, randomized controlled trial, patients with solitary, secretory, and nonmetastatic PPGL were randomized to oral prazosin gastrointestinal therapeutic system (GITS) (maximum 30 mg, n = 9) or amlodipine (maximum 20 mg, n = 11). The primary outcomes were the episodes and duration of hypertension (systolic blood pressure ≥ 160 mmHg) and hypotension (mean arterial pressure < 60 mmHg) and duration of HDI (hypertension and/or hypotension) as a percentage of total surgical time (from induction of anesthesia to skin closure).

RESULTS

The median (IQR) episodes (2 [1-3] vs 0 [0-1]; P = 0.002) and duration of hypertension (19 [14-42] vs 0 [0-3] minutes; P = 0.001) and intraoperative HDI duration (22.85 ± 18.4% vs 2.44 ± 2.4%; CI, 8.68-32.14%; P 0.002) were significantly higher in the prazosin GITS arm than the amlodipine arm, whereas episodes and duration of hypotension did not differ between the 2 groups. There was no perioperative mortality. One patient had intraoperative ST depression on the electrocardiogram. The drug-related adverse effects were pedal edema (1 in amlodipine), dizziness (1 in prazosin GITS), and tachycardia (6 in prazosin GITS and 3 in amlodipine).

CONCLUSION

Preoperative blockade with amlodipine is an efficacious alternative to prazosin GITS in preventing intraoperative HDI in PPGL. Larger studies that compare preoperative blockade by amlodipine with other α-blockers like phenoxybenzamine and/or doxazosin in PPGL patients are warranted.

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.

Efficacy of α-Blockers on Hemodynamic Control during Pheochromocytoma Resection: A Randomized Controlled Trial

CONTEXT

Pretreatment with α-adrenergic receptor blockers is recommended to prevent hemodynamic instability during resection of a pheochromocytoma or sympathetic paraganglioma (PPGL).

OBJECTIVE

To determine which type of α-adrenergic receptor blocker provides the best efficacy.

DESIGN

Randomized controlled open-label trial (PRESCRIPT; ClinicalTrials.gov NCT01379898).

SETTING

Multicenter study including 9 centers in The Netherlands.

PATIENTS

134 patients with nonmetastatic PPGL.

INTERVENTION

Phenoxybenzamine or doxazosin starting 2 to 3 weeks before surgery using a blood pressure targeted titration schedule. Intraoperative hemodynamic management was standardized.

MAIN OUTCOME MEASURES

Primary efficacy endpoint was the cumulative intraoperative time outside the blood pressure target range (ie, SBP >160 mmHg or MAP <60 mmHg) expressed as a percentage of total surgical procedure time. Secondary efficacy endpoint was the value on a hemodynamic instability score.

RESULTS

Median cumulative time outside blood pressure targets was 11.1% (interquartile range [IQR]: 4.3-20.6] in the phenoxybenzamine group compared to 12.2% (5.3-20.2)] in the doxazosin group (P = .75, r = 0.03). The hemodynamic instability score was 38.0 (28.8-58.0) and 50.0 (35.3-63.8) in the phenoxybenzamine and doxazosin group, respectively (P = .02, r = 0.20). The 30-day cardiovascular complication rate was 8.8% and 6.9% in the phenoxybenzamine and doxazosin group, respectively (P = .68). There was no mortality after 30 days.

CONCLUSIONS

The duration of blood pressure outside the target range during resection of a PPGL was not different after preoperative treatment with either phenoxybenzamine or doxazosin. Phenoxybenzamine was more effective in preventing intraoperative hemodynamic instability, but it could not be established whether this was associated with a better clinical outcome.