Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access
Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc
Journal website https://www.jofem.org

Original Article

Volume 13, Number 1, February 2023, pages 20-32

Predictors of Perioperative Hypertensive Crisis in Patients With Pheochromocytoma: A Retrospective Study

Figures

Figure 1.
Figure 1. Receiver operating characteristic (ROC) curve of hypertensive crisis during surgery by tumor size reported by imaging. The size of the tumor in mm has at least one tie between the positive actual state group and the negative actual state group. Area: 0.667, P = 0.082, 95% confidence interval: 0.499 - 0.835.
Figure 2.
Figure 2. Systolic blood pressures (SBPs) at different times in patients with and without hypertensive crisis during surgery. Mean SBPs at different times: SBP on admission; PreOp: on the day of surgery; Operative: in the operative room during surgery; PostOp: postoperatively. HTN: hypertension.
Figure 3.
Figure 3. Diastolic blood pressures (DBPs) at different times in patients with and without hypertensive crisis during surgery. Mean DBPs at different times: DBP on admission; PreOp: on the day of surgery; Operative: in the operative room during surgery; PostOp: postoperatively. HTN: hypertension.

Tables

Table 1. Demographic and Therapeutic Details of the Patients
 
Case numberSexAge (years)PhB/dTumor sizeaTumor sideSymp. or Dx. durationbPheo panelSurgery techniqueHTCHypotensive drugAdmitBPePreopBPcOpBPPostOp BPΒ-blockerACEI or ARBAmlodipineNL saline
aIn millimeters, imaging. bDefined as the time took for the patient from symptom started or probable diagnosis by imaging to refer to the hospital. cPreoperative BP is defined as the first non-invasive blood pressure recorded on arrival to the operating room. d+/- is defined as positive/negative in laboratory data or whether or not experienced a condition or taken or not taken medication. “?” is defined as unavailable data. eAll blood pressures are recorded in mm Hg. F: female; M: male; PhB/d: phenoxybenzamine administered per day in mg/day; Pheo: pheochromocytoma; HTC: hypertensive crisis; BP: blood pressure; Op: operative; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; NL saline: normal saline serum; Lap: laparoscopic.
1F3940.017Left2 months+dLap--135/95130/70120/80180/93+--+
2F3131.054Right1 month+Open--113/62140/80132/80110/70---+
3M5360.036Right3 months+Lap--130/80140/80135/80120/80+---
4F5624.229Right6 months-Lap--130/80113/76135/75103/77+-++
5F5220.08.5Right3 months-Lap--135/80150/90125/75125/82++++
6F4815.070Left6 months+Lap++125/80130/80180/105120/80+--+
7M2120.080Left17 months+Lap--130/80150/100100/75100/60+--+
8M2528.724Right24 months-Lap--130/80115/70120/75130/80+--+
9M5159.562Right3 months+Lap--140/90130/70125/80130/80++++
10M4346.380Left72 months+Open++150/90160/80180/100125/98+-++
11F3032.660Left24 months+Open--100/60150/100130/8593/61+--+
12F3520.080Right9 months-Lap--110/70110/70120/80114/68+--+
13M5538.720Left5 months+Open--200/110140/90135/85130/90---+
14F3319.253Right24 months-Open--115/85120/80130/75111/79+--+
15F4816.737Right24 months-Lap++120/70130/80180/120137/93++--
16F5419.643Right10 months+Lap--130/80102/82125/85110/76+--+
17M4718.086Right1 month+Open--150/100140/80130/80130/90++-+
18F7218.030Left2 months+Lap--130/80140/80135/75107/75++++
19F2713.635Right60 months+Lap++119/69140/90170/110115/95+-+-
20M3838.990Left24 months+Open--122/81140/90135/75128/70++++
21M2337.773Bilateral1 month+Open++160/70110/70180/110133/78++++
22M5632.027Right12 months+Lap--110/70150/90130/80108/66++-+
23M5614.430Right3 months+Lap--130/80120/80120/75120/87+-+-
24M3245.038Left2 months+Lap++130/80165/95165/95110/74+-++
25F6834.034Right1 month?Lap++233/122130/80180/90144/92++++
26F5226.830Left3 months?Lap--165/100126/76130/75134/74++++
27M5521.278Right1 month+Lap--130/90130/87125/7593/65---+
28F7058.395Left24 months-Open++175/110130/80190/120112/73+-++
29F4518.034Right7 months+Lap--150/100140/90125/70108/70+-++
30M3317.549Left6 months+Lap--120/70130/80125/80116/70+--+
31F6325.040Right3 months+Open--160/80140/80130/75117/95+--+
32F3421.035Left48 months+Open--130/80120/80125/70113/69++-+
33M4242.155Bilateral1 month?Open--125/85140/80120/80120/80+--+
34F4712.035Right24 months-Lap--120/80110/70120/75120/70+--+
35F6133.630Right5 months+Lap--120/80120/80120/75120/80+-++
36M6240.035Left6 months+Lap--110/70120/80130/80145/90+---
37F3718.654Left6 months+Open--120/80150/80125/75105/68+--+
38M5830.050Left24 months+Open++130/90120/80170/110110/79+---
39F5535.344Right8 months+Open--120/80145/85120/8092/50+-++
40M3630.865Right72 months-Open++125/100140/80160/100115/68+-++
41F4419.020Right8 months-Lap++160/80140/80190/100117/95--++
42F2311.530Left12 months-Lap--90/60140/90125/80122/93+--+
43M1523.240Left4 months+Lap--150/90134/84120/75106/53+--+
44M5553.065Right192 months-Lap--170/9084/46120/80105/63++-+
45F5364.330Right12 months+Lap--140/95115/106125/70125/89++++
46F4620.030Right8 months?Lap--120/60140/80120/70102/63---+
47F4511.933Right12 months+Lap--100/60122/71120/75100/52+--+
48F6027.030Right8 months-Lap--150/90110/70125/75128/88++++
49M3052.015Right4 months+Lap--136/98120/70120/75130/95-+++
50M5930.156Left6 months+Open--110/70120/70130/8097/52+---
51F4835.016Right3 months+Lap--110/70120/80120/80134/81+--+
52M3157.547Right24 months+Lap++110/70150/90195/110160/110+--+

 

Table 2. Risk Factors of Hypertensive Crisis During Surgery
 
VariablesHTC (N = 12)No HTC (N = 40)P*
aDays that patients took phenoxybenzamine, from the day started to the day of the surgery. bWe defined this hypotensive drug as the drug which the patient took during HTC in surgery such as sodium nitroprusside or phentolamine. *Resulted from Mann-Whitney or independent samples t-test for continuous and Chi-squared for categorical data. Data are presented as mean ± standard deviation, and median interquartile range (first quartile - third quartile) for continuous and frequency (percentage) for categorical data. P ≤ 0.05 is statistically significant. HTC: hypertensive crisis; PhB: phenoxybenzamine; Pheo: pheochromocytoma; VMA: vanillymandelic acid; BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker.
Sex0.386
  Female6 (50.0%)24 (60.0%)
  Male6 (50.0%)16 (40.0%)
Age44.0 ± 15.3, 43.5 (31.5 - 55.5)45.60 ± 13.2, 47.5 (34.5 - 55)0.724
PhB (mg)642.5 ± 552.4, 440.0 (170.0 - 1,025.0)548.5 ± 441.5, 465.0 (235.0 - 695.0)0.545
PhB/day (mg/day)33.6 ± 15.8, 32.4 (17.8 - 45.6)29.3 ± 13.8, 25.9 (19.4 - 37.0)0.362
Days PhB takena16.5 ± 9.6, 11.5 (10.0 - 27.5)20.7 ± 18.0, 14.5 (10.0 - 20.5)0.447
Tumor size (imaging)0.038
  ≤ 33.5 mm1 (8.3%)17 (42.5%)
  > 33.5 mm11 (91.7%)23 (57.5%)
Tumor side0.963
  Right6 (50.0%)25 (62.5%)
  Left5 (41.7%)14 (35.0%)
  Bilateral1 (8.3%)1 (2.5%)
Pheo panel0.470
  Positive7 (58.3%)29 (72.5%)
  Negative4 (33.3%)8 (20.0%)
  Unknown1 (8.3%)3 (7.5%)
Pheo panel
  Metanephrine495.0 ± 691.4, 246.0 (88.0 - 431.0)634.7 ± 830.6, 241.0 (153.0 - 611.0)0.707
  Normetanephrine1,172.8 ± 1,005.2, 916.5 (293.0 - 2,044.0)1,114.2 ± 1,044.1, 780.0 (461.0 - 1,277.0)0.912
  Epinephrine20.0 ± 26.9, 20.0 (1.0 - 39.0)68.7 ± 98.6, 28.9 (4.7 - 75.5)0.508
  Norepinephrine728.7 ± 987.4, 332.0 (166.0 - 1,092.0)523.0 ± 648.9, 299.9 (81.1 - 644.0)0.638
  VMA14.1 ± 7.2, 15.6 (15.2 - 16.43)72.9 ± 290.8, 7.0 (4.7 - 21.1)0.659
Type of surgery0.377
  Laparoscopic7 (58.3%)28 (70.0%)
  Open5 (41.7%)12 (30.0%)
Hypotensive drugb< 0.001
  Taken12 (100%)0
  Not taken040 (100%)
BPs
  Admit
    SBP144.7 ± 34.2, 130.0 (122.5 - 160.0)129.6 ± 20.9, 130.0 (117.5 - 138.0)0.067
    DBP85.9 ± 17.2, 80.0 (70.0 - 95.0)81.0 ± 12.3, 80.0 (70.0 - 90.1)0.278
  PreOp
    SBP137.1 ± 15.7, 135.0 (130.0 - 145.0)128.9 ± 15.2, 130.0 (120.0 - 140.0)0.111
    DBP82.8 ± 6.5, 80.0 (80.0 - 85.0)80.3 ± 10.4, 80.0 (73.5 - 86.0)0.584
  Operative
    SBP178.3 ± 10.5, 180.0 (170.0 - 185.0)125.0 ± 6.7, 125.0 (120.0 - 130.0)< 0.001
    DBP105.8 ± 9.2, 107.5 (100.0 - 110.0)77.1 ± 3.9, 75.0 (75.0 - 80.0)< 0.001
  PostOp
    SBP124.8 ± 15.7, 118.5 (113.5 - 135.0)117.0 ± 16.5, 116.5 (105.5 - 128.0)0.152
    DBP86.2 ± 12.6, 86.0 (76.0 - 95.0)74.8 ± 12.6, 75.5 (67.0 - 84.5)0.008
Abdominal pain0.072
  Did have4 (33.3%)4 (10.0%)
  Did not have8 (66.7%)36 (90.0%)
Β-blocker0.576
  Taken11 (91.7%)35 (87.5%)
  Not taken1 (8.3%)5 (12.5%)
ACEI or ARB0.523
  Taken3 (25.0%)12 (30.0%)
  Not taken9 (75.0%)28 (70.0%)
Amlodipine0.054
  Taken8 (66.7%)14 (35.0%)
  Not taken4 (33.3%)26 (65.0%)
Normal saline0.186
  Taken9 (75.0%)36 (90.0%)
  Not taken3 (25.0%)4 (10.0%)

 

Table 3. Logistic Regression Analysis for Predicting HTC During Surgery
 
FactorOR95% CI for ORP
Variables with a P < 0.1 in univariate analysis were included in the multivariate logistic regression. Data are shown as odds ratios (ORs) with 95% confidence intervals (CIs). HTC: hypertensive crisis; SBP: systolic blood pressure.
Tumor size (imaging)1.26 - 135.260.031
  ≤ 33.5 mm1
  > 33.5 mm13.06
Abdominal pain0.58 - 25.050.165
  Did not have1
  Did have3.81
Admission SBP1.020.98 - 1.060.269
Amlodipine0.97 - 56.740.05
  Not taken1
  Taken5.09