Risk Factors For Hemodynamic Instability Research Articles

Adrenalectomy for pheochromocytoma: Surgical outcomes and preoperative risk factors for hemodynamic instability.

Surgical resection for pheochromocytoma (PCC) is still challenging. This study assessed the perioperative outcomes of adrenalectomy for PCC and investigated the risk factors for intraoperative hemodynamic instability (HI). This retrospective study included 571 patients with adrenal tumors who underwent adrenalectomy at Kobe University Hospital and other related hospitals between April 2008 and October 2023. The perioperative outcomes of laparoscopic adrenalectomy were compared between PCC (n = 92) and non-PCC (n = 464) groups. In addition, we investigated several potential risk factors for intraoperative HI in patients with PCC (n = 107; open, n = 11; laparoscopic, n = 92; robot-assisted, n = 4). While patients with PCC had a significantly larger amount of blood loss in comparison to those with non-PCC (mean, 70 and 30 mL, respectively; p = 0.004), no significant difference was observed in the rate of perioperative grade ≥III complications (1.1% vs. 0.6%; p = 0.516), and no perioperative mortality was observed in either group. A tumor size of ≥40 mm, with preoperative hypertension and urinary metanephrines at a level ≥3 times the upper limit of the normal value, were found to be significant predictors of HI, with odds ratios of 2.74 (p = 0.025), 3.91 (p = 0.005), and 3.83 (p = 0.004), respectively. Our data suggest that laparoscopic adrenalectomy for PCC may be as safe as that for other types of adrenal tumors and that large tumors and hormonally active disease may be risk factors for intraoperative HI. The optimal perioperative management for PCC with these risk factors should be established.

Clinical efficacy of tolvaptan in acute decompensated heart failure patients with severe aortic stenosis and atrial fibrillation: a sub-analysis from the LOHAS registry.

Severe aortic valve stenosis (AS) and atrial fibrillation (AF) are risk factors of hemodynamic instability in heart failure (HF) management due to low cardiac output, respectively. Therefore, the treatment of HF due to severe AS complicated with AF is anticipated to be difficult. Tolvaptan, a vasopressin V2 receptor inhibitor, is effective in controlling acute decompensated heart failure (ADHF) with hemodynamic stability. However, its clinical efficacy against ADHF caused by AS with AF remains to be determined. Clinical information (from September 2014 to December 2017) of 59 patients diagnosed with ADHF due to severe AS (20 patients with AF; 39 patients with sinus rhythm [SR]) was obtained from the LOHAS registry. The registry collected data from seven hospitals and assessed the short-term effects of tolvaptan in patients hospitalized for ADHF with severe AS. We attempted to identify clinical differences from baseline up to 4days, comparing patients with AF (AF group) versus those with SR (SR group). There were no significant differences between the groups in age (83.7 ± 4.5 vs. 85.8 ± 6.9years, respectively; p = 0.11) and aortic valve area (0.60 [0.46-0.73] vs. 0.56 [0.37-0.70] cm2, respectively; p = 0.50). However, left atrial volume was larger (104 [85-126] vs. 87 [64-103] mL, respectively; p < 0.01), whereas stroke volume was lower (51.6 ± 14.8 vs. 59.0 ± 18.7mL, respectively; p = 0.08) in the AF group versus the SR group. Body weight decreased daily from baseline up to day 4 in both groups (from 55.4 to 53.2kg [p < 0.01] and from 53.5 to 51.0kg [p < 0.01], respectively) without change in heart rate. Notably, the systolic blood pressure decreased slightly in the AF group after 2days of treatment with tolvaptan. Short-term treatment with tolvaptan improved HF in patients hospitalized for severe AS, regardless of the presence of AF or SR. After achieving sufficient diuresis, a slight decrease in blood pressure was observed in the AF group, suggesting an appropriate timeframe for safe and effective use of tolvaptan.

Predictors of hemodynamic instability during and persistent after carotid artery stenting

ObjectivesThe risk factors for post-carotid artery stenting severe hemodynamic instability remain elusive. This study aimed to identify the predictors of severe hemodynamic instability during and persisted after carotid artery stenting. Materials and methodsConsecutive patients who underwent carotid artery stenting for extracranial carotid artery stenosis at a single-center between September 2018 and July 2021 were retrospectively assessed. The predictive factors of severe hemodynamic instability intraoperation and post-operation were analyzed. ResultsAmong the 139 patients included, 63 experienced severe hemodynamic instability, with 45 and 18 cases occurring intra and postoperatively, respectively. Persistent was observed in 21 patients. Smoke exposure (odds ratio [OR], 2.38; p=0.039), carotid bifurcation stenosis (OR, 0.91; p=0.018), and large-diameter balloon (>4 mm) dilatation (OR, 11.95; p<0.001) were identified as independent risk factors for hemodynamic instability at any stage of carotid artery stenting. Intraoperatively, large-diameter balloon (>4 mm) dilatation was associated with an increased risk of hemodynamic instability occurrence (OR, 4.67; p=0.01), whereas general anesthesia (OR, 0.19; p=0.001) and a longer distance from the stenosis to the carotid bifurcation (OR, 0.89; p=0.01) were negatively associated with hemodynamic instability. Furthermore, smoking exposure (OR, 3.73; p=0.03), large diameter balloon dilatation (OR, 6.12; p=0.032), distance from stenosis to bifurcation (OR, 0.85; p=0.047) and long-stent (40 mm) implantation (OR, 0.84 [95% confidence interval, 0.74–0.95]; p=0.007) could independently predict persistent hemodynamic instability. ConclusionPatients with a smoking history, lesions near the carotid bulb, or dilatation using a large-diameter balloon were most likely to suffer severe hemodynamic instability. General anesthesia can protect against severe hemodynamic instability only intraoperatively. Long-term stent implantation may reduce persistent hemodynamic instability.

Hemodynamic parameters in patients undergoing surgery for pheochromocytoma/paraganglioma: a retrospective study

BackgroundPheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors characterized by hemodynamic instability, caused by the paroxysmal release of catecholamines. Patients may develop cardiovascular complications in the perioperative phase due to the massive release of catecholamines, particularly during anesthetic induction and surgical manipulation of the tumor. The aim of this retrospective study was to evaluate the risk factors involved in perioperative hemodynamic instability in patients who underwent surgery for chromaffin tumors.MethodsForty patients (median age 55 [36.50–64.50]) undergone surgery for PHEO/abdominal PGL from January 2011 to December 2016 at the AOU Careggi (Florence, Italy) were retrospectively evaluated. Systolic, diastolic, and mean blood pressure were considered at baseline and during surgery. Patients with blood pressure steadily < 140/90 mmHg before surgery were considered “adequately prepared”. A preoperative therapy with doxazosin, a selective alpha-1 blocker, was started in all patients for at least 14 days prior to the surgery. The presence of hemodynamic instability was reported.ResultsComparing males and females, a significant difference in doxazosin daily dose (p = 0.018), systolic blood pressure (p = 0.048), and in the proportion of adequately prepared patients (p = 0.031) emerged. A positive correlation between preoperative daily dose of doxazosin, tumor size (B = 0.60, p < 0.001), and urinary normetanephrine levels (B = 0.64, p < 0.001) was also observed. Hemodynamic instability occurred in 30.0% of patients. The absence of adequate preparation (p = 0.012) before surgery, urinary normetanephrine levels (NMNur p = 0.039), and surgery time (minutes) (p = 0.021) resulted as risk factors of hemodynamic instability in our series. The use of intraoperative drugs was higher in patients with hemodynamic instability (p < 0.001). A pre-surgical SBP level of > 133 mmHg (OR = 6 CI95% 1.37–26.20, p = 0.017) and an intraoperative SBP and MBP levels of > 127 mmHg (OR = 28.80 CI95% 2.23–371.0, p = 0.010) and > 90 mmHg (OR = 18.90 CI95% 1.82–196.0, p = 0.014), respectively, were identified as effective thresholds to recognize patients at higher risk of HI.ConclusionsA preoperative therapy with alpha-blockers is useful, but not sufficient to avoid surgical risks. Patients with higher pre-surgical levels of NMNur, pre-surgical SBP > 133 mmHg, and/or intraoperative SBP > 127 mmHg and MBP > 90 mmHg, should be carefully monitored. A multidisciplinary approach is indispensable to optimize the management of PHEOs/abdominal PGLs in order to reduce surgical complications.

PD03-09 WHAT ARE THE PREOPERATIVE RISK FACTORS OF HEMODYNAMIC INSTABILITY DURING ADRENALECTOMY FOR PHEOCHROMOCYTOMA?

You have accessJournal of UrologyCME1 Apr 2023PD03-09 WHAT ARE THE PREOPERATIVE RISK FACTORS OF HEMODYNAMIC INSTABILITY DURING ADRENALECTOMY FOR PHEOCHROMOCYTOMA? Mokhtar Bibi, Yassine Ouanes, Kays Chaker, Mohamed Anouer Madani, Yosri Messoudi, Boutheina Mosbahi, Selma Trabelsi, Kheireddine Mourad Dali, Moez Rahoui, and yassine Nouira Mokhtar BibiMokhtar Bibi More articles by this author , Yassine OuanesYassine Ouanes More articles by this author , Kays ChakerKays Chaker More articles by this author , Mohamed Anouer MadaniMohamed Anouer Madani More articles by this author , Yosri MessoudiYosri Messoudi More articles by this author , Boutheina MosbahiBoutheina Mosbahi More articles by this author , Selma TrabelsiSelma Trabelsi More articles by this author , Kheireddine Mourad DaliKheireddine Mourad Dali More articles by this author , Moez RahouiMoez Rahoui More articles by this author , and yassine Nouira yassine Nouira More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Adrenalectomy for pheochromocytoma is considered to be a challenging procedure because of the risk of hemodynamic instability (HI), which is poorly defined and unpredictable. Our study aimed to determine the predictive factors for perioperative HI in patients undergoing unilateral adrenalectomy for pheochromocytoma. METHODS: Between January 2005 and December 2021, 45 patients underwent unilateral adrenalectomy for pheochromocytoma in department of urology La Rabta Hospital. HI was defined as an occurrence of intraoperative episodes of systolic blood pressure above 200 mmHg, mean arteral pressure under 60 mmHg or vasoactive drug administration. Patients were divided into 2 groups depending on presence or absence of intraoperative HI. Patient demographics, tumor characteristics and perioperative hemodynamics were noted. A multivariable logistic regression analysis was performed to determine the independent preoperative risk factors for HI. RESULTS: There was no postoperative mortality, and HI was noted 71.1% (32 patients). Open and laparoscopic adrenalectomy were performed in 36 and 9 patients respectively. Mean tumor size was 54.52 mm. Univariate analysis showed that gender, tumor size, tumoral necroses, B blockers treatment were significantly associated with Hi (p=0.019, p=0.00 01, p=0.0001, p=0.01, respectively). IH was correlated with Systolic blood pressure at incision, adrenal artery clamping and tumour removal (p=0.018, p=0.001, p=0.046, p=0.048, respectively). The multivariate logistic regression analysis showed that tumor size was an independent risk factors for intraoperative hemodynamic instability (OR 2.79, 95% CI: 1-61.8, p=0.008). CONCLUSIONS: Tumour size was the independant predictive factor with hemodynamic instability during adrenalectomy for pheochromocytoma. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e78 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mokhtar Bibi More articles by this author Yassine Ouanes More articles by this author Kays Chaker More articles by this author Mohamed Anouer Madani More articles by this author Yosri Messoudi More articles by this author Boutheina Mosbahi More articles by this author Selma Trabelsi More articles by this author Kheireddine Mourad Dali More articles by this author Moez Rahoui More articles by this author yassine Nouira More articles by this author Expand All Advertisement PDF downloadLoading ...

Mildly Elevated Pulmonary Artery Systolic Pressure is Associated with Extracorporeal Membrane Oxygenation Support after Heart Transplantation

Background. Pulmonary hypertension is a well-known risk factor for hemodynamic instability after heart transplantation. However, it remains unclear whether a mild elevation of pulmonary artery systolic pressure (PASP) is associated with higher risks of graft dysfunction and resultant extracorporeal membrane oxygenation (ECMO) support. Methods. From 2016 to 2021, 102 adult recipients undergoing orthotopic heart transplantation at our institution were investigated (mean age, 48.5 ± 13.2 years; 22.5% female). This study cohort was stratified into 3 groups based on the PASP measured by right heart catheterization before surgery: &gt;50 mmHg, 35–50 mmHg, and &lt;35 mmHg. The primary end point was ECMO support after procedure. Results. ECMO was implemented in 24 (23.5%) patients due to difficult weaning from cardiopulmonary bypass or cardiac low output in the intensive care unit, which was likely to be associated with higher mortality ( P = 0.053 ). Age, gender, comorbidities, preoperative medications, and graft ischemia time were comparable across the 3 groups. The use of ECMO was significantly more common in patients with baseline PASP &gt;50 mmHg (11/36, 30.6%) and 35–50 mmHg (12/38, 31.6%), while only 1 (3.6%) patient with baseline PASP &lt;35 mmHg required ECMO support after transplant ( P = 0.007 ). Multivariate logistic models demonstrated that PASP (odds ratio = 2.34; P = 0.028 ) and cardiopulmonary bypass time (odds ratio = 1.01; P &lt; 0.001 ) were independent risk factors for postoperative ECMO. Conclusions. A mild elevation of pretransplant PASP (e.g., 35–50 mmHg) is related to low cardiac output and subsequent ECMO after heart transplantation, for which prompt administration of vasodilators before transplant may be protective.

Comparison of the retroperitoneal laparoscopic adrenalectomy versus transperitoneal laparoscopic adrenalectomy for large (≥6cm) pheochromocytomas: A single-centre retrospective study.

To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy (RLA) and transperitoneal laparoscopic adrenalectomy (TLA) in the treatment of large (≥6cm) adrenal pheochromocytomas. We retrospectively collected the clinical data of 130 patients with large pheochromocytoma who underwent RLA or TLA in our hospital from 2012 to 2022. The perioperative parameters and follow-up outcomes of the two groups were compared, and univariate and multivariate analyses were used to evaluate the risk factors of hemodynamic instability (HI). A total of 57 patients underwent TLA and 73 underwent RLA. There was no difference in demographic characteristics such as age, sex and tumor size between the two groups. Compared with the TLA group, patients in the RLA group had shorter operation time (P<0.001) and less estimated blood loss (EBL) (P<0.001). The time to ambulation, time to oral food and time to removal of drainage of RLA group were earlier than those of TLA group. In addition, the hospital stay was shorter in the RLA group than in the TLA group. There were no differences in HI, complications, or blood pressure (BP) improvement between the two groups. The mean follow-up time was 61.4 and 65.5 months, respectively, during which no tumors recurred or metastasized. Multivariate analysis showed that elevated hormone levels and larger tumor size were independent risk factors for HI. Both RLA and TLA are effective treatment methods for large pheochromocytomas, but the perioperative outcomes of RLA are better than that of TLA. Our study demonstrates the superiority of RLA for the treatment of large pheochromocytomas.

Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology.

Attaining the optimal balance between achieving adequate volume removal while preserving organ perfusion is a challenge for patients receiving maintenance hemodialysis. Current strategies to guide ultrafiltration are inadequate. We developed an approach to calculate plasma refill rate throughout hemodialysis using hematocrit and ultrafiltration data in a retrospective cohort of patients receiving maintenance hemodialysis at 17 dialysis units from January 2017-October 2019. We studied whether (1) plasma refill rate is associated with traditional risk factors for hemodynamic instability using logistic regression, (2) low starting plasma refill rate is associated with intradialytic hypotension using Cox proportional hazard regression, and (3) time-varying plasma refill rate throughout hemodialysis is associated with hypotension using marginal structural modeling. During 180,319 hemodialysis sessions among 2554 patients, plasma refill rate had high within- and between-patient variability. Female sex and hypoalbuminemia were associated with low plasma refill rate at multiple time points during the first hour of hemodialysis. Low starting plasma refill rate had higher hazards of intradialytic hypotension while high starting plasma refill rate was protective (HR 1.26, 95% CI 1.18, 1.35 versus HR 0.79, 95% CI 0.73, 0.85, respectively). However, when accounting for time-varying plasma refill rate and time-varying confounders, compared to a moderate plasma refill rate, while a consistently low plasma refill rate was associated with increased risk of hypotension (OR 1.09, 95% CI 1.02, 1.16), a consistently high plasma refill rate had a stronger association with hypotension within the next 15 minutes (OR 1.38, 95% CI 1.30, 1.45). We present a straightforward technique to quantify plasma refill that could easily integrate with devices that monitor hematocrit during hemodialysis. Our study highlights how examining patterns of plasma refill may enhance our understanding of circulatory changes during hemodialysis, an important step to understanding how current technology might be utilized to improve hemodynamic instability.

Risk factors for hemodynamic instability during laparoscopic resection of pheochromocytoma

BackgroundLaparoscopic adrenalectomy for pheochromocytoma is associated with high risk of intraoperative hemodynamic instability. Our study aimed to identify predictive factors for hemodynamic instability during laparoscopic resection of pheochromocytoma.MethodsBetween January 2011 and December 2021, 136 patients underwent unilateral laparoscopic adrenalectomy for pheochromocytoma. The patients were divided into 2 groups depending on the presence or absence of hemodynamic instability during surgery. Intraoperative hemodynamic parameters were compared between the 2 groups. Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to intraoperative hemodynamic instability via both univariate analysis and multivariate logistic regression analysis.ResultsThere was greater blood pressure fluctuations and higher maximum blood pressure and heart rate in the hemodynamic instability group. More patients need intraoperative administration of vasoactive drugs in the hemodynamic instability group. In the univariate analysis, presence of coronary artery disease, tumour size, and previous hypertension history were significantly associated with intraoperative hemodynamic instability. The multivariate logistic regression analysis showed that tumour size and previous hypertension history were independent risk factors for intraoperative hemodynamic instability.ConclusionTumour size and previous hypertension history were associated with hemodynamic instability during laparoscopic resection of pheochromocytoma.

Risk factors for haemodynamic instability and its prolongation during laparoscopic adrenalectomy for pheochromocytoma.

Pheochromocytoma is a rare neuroendocrine tumour that secretes catecholamines and originates in the adrenal gland. Although surgical resection is the only curative therapy for pheochromocytoma, it is associated with a risk of haemodynamic instability (HDI), such as extremelyhigh blood pressure and/or post tumour removal hypotension and shock. We investigated the risk factors for HDI during pheochromocytoma surgery. Eighty-two patients who underwent laparoscopic adrenalectomy for pheochromocytoma between July 2002 and February 2020 were examined. We excluded 3 patients with bilateral disease and 11 without detailed 24 hurinary data. We defined HDI as systolic blood pressure ≥ 200or <80 mmHg. We investigated the risk factors for HDI during laparoscopic adrenalectomy for pheochromocytoma. There were 29 males and 39 females with a median age of 50.5 years. Tumours were localised on the right adrenal gland in 28 patients and on the left in 40. The median tumour diameter was 37.5 mm and the median pneumoperitoneum time was 93.5 min. Twenty-five out of sixty-eight patients (37%) developed HDI. A multivariate analysis identified diabetes mellitus (DM; odds ratio: 3.834; 95% confidence interval: 1.062-13.83; p = .04) as an independent predictor of HDI. In terms of hormonal data, median 24 hurinary epinephrine levels (p = .04) and metanephrine levels (p = .01) were significantly higher in the HDI group. DM was also considered as a risk factor for prolonged HDI (p = .02). Surgeons and anaesthesiologists need to be aware of the risk of HDI and its prolongation during laparoscopic adrenalectomy for pheochromocytoma for DM patients.

Prevalence and risk factors of hemodynamic instability associated with preload-dependence during continuous renal replacement therapy in a prospective observational cohort of critically ill patients

BackgroundHemodynamic instability is a frequent complication of continuous renal replacement therapy (CRRT). Postural tests (i.e., passive leg raising in the supine position or Trendelenburg maneuver in the prone position) combined with measurement of cardiac output are highly reliable to identify preload-dependence and may provide new insights into the mechanisms involved in hemodynamic instability related to CRRT (HIRRT). We aimed to assess the prevalence and risk factors of HIRRT associated with preload-dependence in ICU patients.We conducted a single-center prospective observational cohort study in ICU patients with acute kidney injury KDIGO 3, started on CRRT in the last 24 h, and monitored with a PiCCO® device. The primary endpoint was the rate of HIRRT episodes associated with preload-dependence during the first 7 days after inclusion. HIRRT was defined as the occurrence of a mean arterial pressure below 65 mmHg requiring therapeutic intervention. Preload-dependence was assessed by postural tests every 4 h, and during each HIRRT episode. Data are expressed in median [1st quartile–3rd quartile], unless stated otherwise.Results42 patients (62% male, age 69 [59–77] year, SAPS-2 65 [49–76]) were included 6 [1–16] h after CRRT initiation and studied continuously for 121 [60–147] h. A median of 5 [3–8] HIRRT episodes occurred per patient, for a pooled total of 243 episodes. 131 episodes (54% [CI95% 48–60%]) were associated with preload-dependence, 108 (44%, [CI95% 38–51%]) without preload-dependence, and 4 were unclassified. Multivariate analysis (using variables collected prior to HIRRT) identified the following variables as risk factors for the occurrence of HIRRT associated with preload-dependence: preload-dependence before HIRRT [odds ratio (OR) = 3.82, p < 0.001], delay since last HIRRT episode > 8 h (OR = 0.56, p < 0.05), lactate (OR = 1.21 per 1-mmol L−1 increase, p < 0.05), cardiac index (OR = 0.47 per 1-L min−1 m−2 increase, p < 0.001) and SOFA at ICU admission (OR = 0.91 per 1-point increase, p < 0.001). None of the CRRT settings was identified as risk factor for HIRRT.ConclusionsIn this single-center study, HIRRT associated with preload-dependence was slightly more frequent than HIRRT without preload-dependence in ICU patients undergoing CRRT. Testing for preload-dependence could help avoiding unnecessary decrease of fluid removal in preload-independent HIRRT during CRRT.

Hemodynamic Instability during Thyroidectomy in Graves’ Disease

Background The aim of this study was to investigate the changes in vital signs and hemodynamic status that occur in patients during the intraoperative course of thyroidectomy in Graves’ Disease (GD). Methods A total of 71 patients were included in the study. Patients were directed to surgery when they had large goiters with compressive symptoms or suspicious nodules, were pregnant or lactating, were unresponsive or intolerant to antithyroid drugs (ATDs), or expressed a preference to have surgery. All patients scheduled for operations underwent surgery while in the euthyroid state. Results Hemodynamic instability was observed in 18 patients during thyroidectomy. Disease duration, sample weight, and thyroid-stimulating hormone receptor antibodies (TRAb) levels were found to be effective on hemodynamic instability. Logistic regression analysis revealed an 11-fold increase in the instability risk in patients with a period of disease shorter than 21 months (P = 0.037). A TRAb value >11.5 increased the risk by 235fold (p < 0.001). Conclusion High levels of TRAb values and new onset of disease with shorter periods of ATDs use may be risk factors for hemodynamic instability during thyroidectomy. Patients with larger thyroid glands are at greater risk for instability during surgery. Those risks should be taken into account during surgery, and the surgical and anesthetic management of the patient should be made more carefully in concordance with the anesthesia team.

Factors associated with hemodynamic instability following carotid artery stenting

ObjectiveCarotid artery stenting (CAS) is a major treatment option for carotid artery stenosis, and a recognized alternative to carotid endarterectomy (CEA). However, CAS-related hemodynamic instability occurs frequently and is a known major risk factor of associated complications. This study was undertaken to identify the risk factors of hemodynamic instability associated with CAS. MethodsWe analyzed the medical records of 128 patients with carotid artery stenosis treated by CAS at our institution from 2014 to 2019 to identify the risk factors of hemodynamic instability after CAS. In addition, the incidences of hemodynamic instability, including bradycardia and hypotension, during and after the procedure were investigated. ResultsOverall, periprocedural bradycardia requiring atropine occurred in 18 (14.1 %) of the 128 study subjects, and postprocedural persistent hypotension requiring vasopressors occurred in 15 (11.7 %). Risk-adjusted analysis showed carotid bulb involvement of a stenotic lesion was an independent risk factor of periprocedural bradycardia (OR 4.25, 95 % CI 1.34−13.40) and postprocedural persistent hypotension (OR 7.36, 95 % CI 1.86−29.12). However, though a preoperative regimen of ≥ 2 antihypertensives was found to be an independent protective factor against postprocedural persistent hypotension (OR 0.17, 95 % CI 0.04−0.81), it was not associated with periprocedural bradycardia (OR 0.37 95 % CI 0.08−1.60). ConclusionsThe risk of hemodynamic instability development is greater when a carotid stenotic lesion involves the carotid bulb, which cautions that careful evaluation is necessary. In addition, the receipt of antihypertensive regimens before CAS had a protective effect on persistent hypotension after CAS, but did not affect bradycardia.

Risk factors for hemodynamic instability during laparoscopic pheochromocytoma resection: a retrospective cohort study.

Adrenalectomy for pheochromocytoma, a rare catecholamine-secreting tumour, is a challenging procedure because of the high risk of intraoperative hemodynamic instability, which can cause life-threatening complications. Our study aimed to identify predictive factors for hemodynamic instability during pheochromocytoma resection as well as to assess the risk factors for postoperative morbidity. Data of 96 patients, who underwent laparoscopic adrenalectomy were analysed retrospectively. Hemodynamic instability was defined as an occurrence of both intraoperative episodes of systolic blood pressure above 160 mmHg and vasoactive (vasodilators or vasoconstrictors) drug administration. Patients were divided into two groups: one which met both criteria, and another one without hemodynamic instability-42 (43.8%) and 54 (56.2%) respectively. The mean tumour size was 4.5±2.0 cm. 86 patients had a sporadic pheochromocytoma and 10 (10.4%) had a familial disease. Sixty-three patients were preoperatively treated with nonselective blockers and 33 patients with selective blockers. Mean operative time was 98.7±41.7 min. and mean intraoperative blood loss was 165.7±381.2 mL. In 26% of patients, postoperative complications occurred. The median length of hospital stay was 3 days. The multivariate logistic regression model showed that the size of adrenal tumour and diabetes were significant factors of hemodynamic instability. Intraoperative use of vasopressors was an independent risk factor for both all-cause and cardiovascular morbidity. Adrenal tumour size and diabetes were associated with hemodynamic instability during pheochromocytoma resection. The only risk factor for complications in our group was intraoperative necessity to use vasopressors.

Predictors of hemodynamic instability in patients with pheochromocytoma and paraganglioma.

Background and ObjectivesIntraoperative hemodynamic instability is common in patients with pheochromocytoma and paraganglioma. The aim of this study was to identify the predictive risk factors of intraoperative hemodynamic instability.MethodsA total of 428 patients having elective resection of pheochromocytoma and/or paraganglioma at Peking Union Medical College Hospital between January 2014 and July 2019 were included. The association between preoperative parameters and the incidence of intraoperative hemodynamic instability were evaluated. Binary logistic regression was used to assess the predictive risk factors of hemodynamic instability.ResultsPatients with intraoperative hemodynamic instability were more prone to have elevated levels of norepinephrine and epinephrine. Binary Logistic regression showed the risk factors of hemodynamic instability were tumor size >5.0 cm (odds ratio [OR], 1.889; 95% confidence interval [CI], 1.243‐2.870; P = .003) and five‐fold increases of urine epinephrine (OR, 2.195; 95% CI, 1.242‐3.880; P = .007).ConclusionsIntraoperative hemodynamic instability is common despite adequate preoperative medical treatment. Tumor size and high level of urinary epinephrine are tumor‐related factors for intraoperative hemodynamic instability. Identifying these factors can help clinicians to manage patients more effectively and improve patients' outcomes.

Prevalence and risk factors of hemodynamic instability during endoscopic transsphenoidal pituitary surgery: a retrospective analysis

Objective: Intraoperative hemodynamic instability in patients undergoing endoscopic transsphenoidal pituitary surgery (ETSS) for pituitary adenoma may lead to significant complications. We aimed to investigate the prevalence of hemodynamic instability and its associated risk factors in these patients. Methods: This retrospective study included patients who underwent ETSS at Ankara Numune Training and Research Hospital between 14 January 2010 and 20 March 2014. Intraoperatively occurring episodes of bradycardia, hypotension, and hypertension were recorded. Distribution of hemodynamic instability was determined based on age groups, ASA class, tumor type, and anesthesia method. Results: A total of 323 patients met the study criteria. Mean age of the patients was 46.88 ± 13.91 years and 54.5% were female. Intraoperative bradycardia was detected in 137 patients (42.41%), hypotension in 57 patients (17.65%), and hypertension in five patients (1.55%). Hemodynamic instability occurred in all of the patients over the age of 51. Patients classified as ASA III were more likely to have hemodynamic instability than patients with ASA I and ASA II (p&amp;lt;0.05). All 18 patients who were transferred to intensive care unit were in the age group of 61 years and over. The rate of hemodynamic instability was higher in patients with non-functioning tumor compared to that in patients with functioning tumors. Conclusion: The rate of intraoperative hemodynamic instability in patients undergoing ETSS is higher in older patients than that in young patients. The elderly has multiple comorbidities and are more sensitive to anesthetic agents. This group needs a carefully planned anesthetic management during perioperative period.

Analysis of risk factors for intraoperative hemodynamic instability in adrenal incident pheochromocytoma

Objective To evaluate the risk factors for intraoperative hemodynamic instability (HI) in patients with adrenal incident pheochromocytoma. Methods Perioperative clinical parameters of patients undergoing surgery for adrenal incident pheochromocytoma at the First Hospital of Peking University from January 2001 to July 2018 were analyzed. There were 39 males and 41 females, with mean age of 45.1 years (13-76 years old). The median tumor length was 5.1 cm (1.5-14.0 cm), with 25 cases (31.3%) on the left side , 55 cases (68.8%) on the right side. There were 37 cases combined with coronary heart disease or diabetes or BMI≥24 kg/m2. Patients were divided into hemodynamic instability (HI group) and hemodynamic stability group (HS group) by whether intraoperative hemodynamic instability occurred. The differences of demographic characteristics and clinical parameters between the two groups were compared. Logistic regression analysis was done for seeking the risk factors for hemodynamic instability during surgery. Results There were 54 cases (67.5%) in the HS group and 26 cases (32.5%) in the HI group. Univariate analysis showed that there was no significant difference in age [(44.06±13.58) years old vs. (47.35±16.11) years old], combined with coronary heart disease or diabetes or BMI≥24 kg/m2 [50.0% (27/54) vs. 38.5% (10/26)], tumor long diameter [median 5.0 cm(1.5-14.0 cm) vs. 6.0cm(1.5-13.5 cm)], tumor location[left: 29.6% (16/54) vs. 34.6% (9/26)], preoperative catecholamine test positive [44.4% (20/45) vs. 50.0% (10/20)], open surgery [27.8% (15/54) vs. 34.6% (9/26)]and preoperative non-alpha blockers[13.0%(7/54) vs. 30.8%(8/26)] between HS group and HI group (P>0.05). Further logistic regression analysis was used to analyze the risk factors of intraoperative hemodynamic instability. Multivariate analysis found that patients who preoperative non-alpha blockers before surgery were independent risk factor for HI (OR=4.574, 95%CI 1.273-16.432, P=0.020). Conclusions Preoperative non-alpha blocker in patients with adrenal incidental pheochromocytoma could be independent risk factor for intraoperative hemodynamic instability. Therefore, it is recommended that patients with adrenal incidental tumors, especially those who fail to rule out pheochromocytoma, take preoperative alpha blockers. Key words: Pheochromocytoma; Adrenal incidentaloma; Hemodynamic; Alpha blocker

Preoperative risk factors for haemodynamic instability during pheochromocytoma surgery in Chinese patients.

Pheochromocytoma surgery carries a high risk of haemodynamic instability (HI). However, there are few studies investigating the risk factors for HI for pheochromocytoma surgery in a Chinese population. Therefore, our objective was to identify preoperative risk factors for HI during surgery in a Chinese population with pheochromocytoma. In this retrospective study, 134 patients undergoing surgery for pheochromocytoma at a single university-affiliated hospital between November 2002 and July 2017 were enrolled. Demographics, comorbidities, preoperative medical preparation, operation details and perioperative haemodynamics of these patients were retrospectively collected and analysed. Multivariable logistic regression analysis was performed to identify the preoperative risk factors for intraoperative HI. 32.8% (44/134) patients suffered from intraoperative HI. According to the result of multivariate analysis, tumour diameter >50mm (odds ratio [OR] 2.526; 95% confidence interval [CI] 1.163-5.485; P=.019), diabetes/prediabetes (OR 2.251; 95% CI 1.039-4.876; P=.040) and preoperative systolic blood pressure fluctuation >50mm Hg (OR 3.163; 95% CI 1.051-9.522, P=.041) were independent predictors for intraoperative HI. The observed incidence of HI was 8.9%, 42.6%, 47.8% and 60% when zero, one, two or three risk factors were present, respectively. HI is common among Chinese patients undergoing surgery for pheochromocytoma. Our study identified three predictive factors for intraoperative HI: a large tumour diameter, diabetes/prediabetes and a great preoperative systolic blood pressure fluctuation. Furthermore, patients are more likely to suffer from HI when they have more predictive risk factors. Identification of these risk factors can help to improve perioperative management.

Predictors of haemodynamic instability during the changeover of norepinephrine infusion pumps.

BackgroundChangeovers of norepinephrine infusion pumps (CNIPs) frequently lead to haemodynamic instability. The aim of this study was to identify risk factors for haemodynamic instability associated with CNIP, independent of the method used to perform the relay.MethodsWe performed a prospective study, in a university-affiliated intensive care unit. Over a 1-year period, all adult patients who had at least one CNIP were included. CNIPs were automatically performed using smart pumps, in accordance with a standardised protocol. CNIP-induced haemodynamic instability was defined as a variation in mean arterial pressure (MAP) >25 %. A multivariate mixed effects logistic regression was fitted to assess the factors associated with CNIP-induced haemodynamic instability.ResultsFrom the 118 patients included in the study, 764 CNIPs were analysed. Most of the patients were treated with norepinephrine for septic shock of medical origin (n = 83, 70 %). Haemodynamic instability occurred 114 times (15 %) in 63 patients (53 %). Among the risk factors identified by the univariate analysis (age, heart rate, dose of norepinephrine infused, and change in the concentration of the vasoactive drug; p < 0.05), change in the norepinephrine concentration was the only independent risk factor for CNIP-induced haemodynamic instability identified in the multivariate analysis (adjusted OR 11.8, 95 % CI 7.2–19.5, p < 0.001).ConclusionsChanges in the norepinephrine concentration during CNIPs lead to a high risk of haemodynamic instability, while the clinical severity of patients, as well as the doses of norepinephrine, was not.

Risk Factors for Dexmedetomidine-Associated Hemodynamic Instability in Noncardiac Intensive Care Unit Patients.

The reported incidence of hypotension and bradycardia in patients receiving dexmedetomidine for sedation commonly exceeds 50%. In this study, we describe the incidence of, patient- and treatment-specific risk factors for, and clinical significance of dexmedetomidine-associated hemodynamic instability. This retrospective cohort study was conducted in critically ill adults receiving dexmedetomidine for sedation at Mayo Clinic Hospital in Rochester, MN, during a 1-year period. The primary end point was hemodynamic instability: a composite of hypotension and/or bradycardia, defined as systolic blood pressure <80 mm Hg, diastolic blood pressure <50 mm Hg, or heart rate <50 beats per minute during dexmedetomidine therapy. Cox proportional hazards models were constructed to determine hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk factors of hemodynamic instability. Hemodynamic instability occurred in 197 of the analyzed 300 patients receiving dexmedetomidine, resulting in a cumulative incidence of 71% at 24 hours via Kaplan-Meier estimation. In addition to dexmedetomidine, univariate analysis identified age, vasopressor use, low baseline arterial blood pressure, and concomitant sedatives as associated with increased risk of hemodynamic instability. Multivariable analysis demonstrated associations between age (HR, 1.23 per 10 years, 95% CI, 1.10-1.38) and low baseline blood pressure (HR, 2.42 at dexmedetomidine initiation, 95% CI, 1.68-3.49) and risk of hemodynamic instability. Variables such as concomitantly administered cardiac medications or sedative therapies and dexmedetomidine infusion rates >0.7 μg/kg/h were not found to be predictors of hemodynamic instability among the analyzed sample. Hemodynamic instability commonly occurs in critically ill adults receiving dexmedetomidine, with more than two thirds of this cohort experiencing hypotension and/or bradycardia within 24 hours of initiation. Increasing age and low baseline arterial blood pressure were associated with the development of hemodynamic instability. These findings suggest that clinicians should be aware of the potential risk of hemodynamic instability when using dexmedetomidine in patients with advanced age or low baseline arterial blood pressure.