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Risk factors for postoperative hypotension after adrenalectomy for phaeochromocytoma: derivation of the PACS risk
Alessandro Parente1, Joseph P Thompson1, Charlotte Crook1
1HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
Insights
A new risk score helps identify patients at low risk of postoperative hypotension (PH) after adrenalectomy for phaeochromocytoma. This allows for selective use of invasive monitoring, optimizing care for these patients.
Area of Science:
- Endocrinology
- Surgical Oncology
- Anesthesiology
Background:
- Adrenalectomy for phaeochromocytoma carries a risk of postoperative hypotension (PH).
- Invasive monitoring is typically recommended for these patients due to PH risk.
- High costs and limited intensive care availability necessitate identifying low-risk patients.
Purpose of the Study:
- To identify patients at low risk of PH after adrenalectomy for phaeochromocytoma.
- To develop a clinical risk score to guide monitoring decisions.
- To potentially avoid invasive monitoring in low-risk individuals.
Main Methods:
- Retrospective data collection from nine UK centers (2012-2020).
- Inclusion of patient demographics, intraoperative, and postoperative hemodynamic parameters.
- Analysis of independent risk factors for PH to develop a clinical risk score.
Main Results:
- PH occurred in 27.4% of 430 patients.
- Independent risk factors for PH included female sex, tumor size, preoperative catecholamine level, open surgery, and epidural analgesia.
- A clinical risk score (AUROC 0.69) stratified patients, with PH risk of 25% in low-risk and 68% in high-risk groups.
Conclusions:
- A derived risk score effectively stratifies patients for PH risk post-adrenalectomy.
- Low-risk patients may be managed on a surgical ward.
- High-risk patients warrant invasive monitoring.
Background:
Due to the risk of postoperative hypotension (PH), invasive monitoring is recommended for patients who undergo adrenalectomy for phaeochromocytoma. Due to high costs and limited availability of intensive care, our aim was to identify patients at low risk of PH who may not require invasive monitoring.
Methods:
Data for patients who underwent adrenalectomy for phaeochromocytoma between 2012 and 2020 were retrospectively collected by nine UK centres, including patient demographics, intraoperative and postoperative haemodynamic parameters. Independent risk factors for PH were analysed and used to develop a clinical risk score.
Results:
PH developed in 118 of 430 (27.4%) patients. On univariable analysis, female sex (p = 0.007), tumour size (p < 0.001), preoperative catecholamine level (p < 0.001), open surgery (p < 0.001) and epidural analgesia (p = 0.006) were identified as risk factors for PH. On multivariable analysis, female sex (OR 1.85, CI95%, 1.09-3.13, p = 0.02), preoperative catecholamine level (OR: 3.11, CI95%, 1.74-5.55, p < 0.001), open surgery (OR: 3.31, CI95%, 1.57-6.97, p = 0.002) and preoperative mean arterial blood pressure (OR: 0.59, CI95%, 0.48-1.02, p = 0.08) were independently associated with PH, and were incorporated into a clinical risk score (AUROC 0.69, C-statistic 0.69). The risk of PH was 25% and 68% in low and high risk patients, respectively.
Conclusion:
The derived risk score allows stratification of patients at risk of postoperative hypotension after adrenalectomy for phaeochromocytoma. Postoperatively, low risk patients may be managed on a surgical ward, whilst high risk patients should undergo invasive monitoring.
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