A patient with pheochromocytoma is at increased risk for hemodynamic instability during surgery. Bruynzeel et al identified risk factors for hemodynamic instability in these patients which can help to identify patients who may require more aggressive management. The authors are from Erasmus Medical Center in Rotterdam.


Patient selection: pheochromocytoma, prior to surgery


Outcomes: times with systolic blood pressure during surgery > 160 mm Hg OR mean arterial pressure (MAP) below 60 mm Hg


Risk factors for hemodynamic instability during surgery:

(1) greater diameter of the pheochromocytoma (> 4 cm)

(2) high plasma concentrations of norepinephrine

(3) postural fall in mean arterial blood pressure after alpha blockade >= 10 mm Hg

(4) mean arterial blood pressure > 100 mm Hg after alpha blockade



• 29% of pheochromocytomas did not produce norepinephrine.

• The median value for norepinephrine was 1,648 pg/mL with range 36 to 250,000.

• The cut-off for norepinephrine was not given, It would also be affected by methodology. A multiple of the upper limit of normal reference range is worth investigating.

• The postural fall in blood pressure is supine mean arterial blood pressure minus upright mean arterial blood pressure).

• On pages 681-682 the postural fall is >= 10 mm Hg but in conclusion it is > 10 mm Hg.

• A mean arterial pressure of 100 mm Hg corresponded to a blood pressure of 130 mm Hg systolic and 85 mm Hg diastolic.


A high mean arterial blood pressure at presentation was also associated with hemodynamic instability during surgery (conclusion, page 685)


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