Primary perioperative haemodynamic effects of ß-receptor blockade in patients with catecholamine-secreting tumours

Abstract

Introduction: Guidelines for the treatment of catecholamine-producing tumours strictly recommend starting ß-receptor blocking medication only after α-receptor blockade has been established. This recommendation is supported only by non-surgical case reports. However, in clinical practice ß-receptor blockade is often started before the diagnosis of a phaeochromocytoma is made. As we routinely treat patients with catecholamine-producing tumours without α-receptor blockade, our aim was to evaluate haemodynamic changes in such patients with and without ß-receptor blockade.

Methods: Perioperative blood pressure was assessed prospectively for all patients. The primary outcome was the highest pre-, intra-, and postoperative systolic blood pressure in patients with or without a ß-receptor blockade. Secondary outcomes were the incidence of intraoperative systolic blood pressure peaks >250 mm Hg and hypotensive episodes. Subsequently, a propensity score matching (PSM) analysis was performed.

Results: Out of 584 phaeochromocytoma and paraganglioma resections, 383 operations were performed without α-receptor blockade (including 84 with ß-receptor blockade). Before operation and intraoperatively, patients with ß-receptor blockade presented with higher systolic blood pressure (155 [25] and 207 [62] mm Hg) than patients without ß-receptor blockade (147 [24] and 183 [52] mm Hg; P=0.006 and P=0.001, respectively). Intraoperatively, patients with ß-receptor blockade demonstrated a higher incidence of hypotensive episodes (25% without vs 41% with ß-blockade; P<0.001). After propensity score matching no difference between the groups could be confirmed.

Conclusion: Overall, patients with isolated ß-receptor blockade developed higher blood pressure before operation and intraoperatively. After propensity score matching a difference could no longer be detected. Overall, ß-receptor blockade seems to be more a sign for severe disease than a risk factor for haemodynamic instability.

Keywords: adrenal surgery; adrenergic blockade; arterial hypotension; haemodynamic instability; paraganglioma; perioperative management; phaeochromocytoma; risk factors.

Fig 1

Consort Flow diagram.

Fig 2

Plot of baseline arterial blood pressure in patients with no adrenoceptor blockade or isolated ß-receptor blockade (purple box=no adrenal blockade, blue box=ß-receptor blockade). There are differences over time between the two groups. Post hoc analysis showed higher preoperative and intraoperative maximum systolic blood pressure values for patients with isolated ß-receptor blockade (P<0.001).

Fig 3

Box plot of baseline arterial blood pressure in patients with no adrenoceptor blockade or isolated ß-receptor blockade (purple box=no adrenal blockade, blue box=ß-receptor blockade) after propensity score matching (74 pairs). No differences between the two groups were found.