Learning curve of blood pressure management during phaeochromocytoma surgery without preoperative alpha-blockade dose escalation

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BACKGROUND: Adrenalectomy without preoperative dose escalation of α-blockade is gaining popularity for managing phaeochromocytoma, showing comparable outcomes but shorter hospital stays and less postoperative hypotension. However, recent data showed an initial significant increase in intraoperative hypotension after transitioning to this approach, suggesting a learning curve. We evaluated this learning curve for the safe use of our α-blockade non-escalation workflow employing a risk-adjusted CUSUM (RA-CUSUM) analysis. METHOD: This single-centre cohort study included phaeochromocytoma resections without preoperative α-blockade dose escalation from 2019 until 2023. All procedures were performed by an experienced operating theatre team, including anaesthesiologists and surgeons dedicated to phaeochromocytoma treatment. Intraoperative hypotension (time-weighted average (TWA) of mean arterial pressure (MAP) < 60 mmHg) was identified as primary learning curve outcome. RA-CUSUM analysis consisted of predicting intraoperative hypotension using a multivariable linear regression model corrected for established risk factors and modelling the relationship between the number of procedures and the cumulative difference in predicted and observed outcomes. RESULTS: A total of 44 procedures were evaluated employing the new preoperative α-blockade non-escalation strategy. RA-CUSUM analysis showed that the learning curve was completed after 19 surgeries. The median TWA of MAP < 60 mmHg was 2.29 (IQR: 0.45-4.16) mmHg. No perioperative complications related to haemodynamic instability occurred in the cohort. Time in the operating theatre and length of hospital stay remained consistent over time. CONCLUSION: Our results confirm that transitioning to phaeochromocytoma resection without α-blockade dose escalation follows a learning curve. To ensure safe implementation, centres adopting the non-escalation workflow should meet certain conditions, with structured guidance or proctoring as possible measures.

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