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Phaeochromocytoma Preparation Sequence — ESENeph MCQ

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ModerateHypertensionPhaeochromocytoma Preparation SequenceESENeph

A 50-year-old man with CKD G4 and resistant hypertension on 4 agents (including ACEi and CCB) is found to have an elevated plasma metanephrine level. 24-hour urinary catecholamines are elevated. CT adrenals shows a 3 cm right adrenal mass. Before surgical removal, what is the essential pre-operative preparation sequence?

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Correct answer: E — Alpha-blockade first, then beta-blockade if tachycardic, then salt and fluid loading

Phaeochromocytoma requires sequential pre-operative preparation: (1) Alpha-blockade first (Phenoxybenzamine or Doxazosin for ≥10-14 days) to prevent hypertensive crisis from catecholamine surge during tumour manipulation; (2) Beta-blockade ONLY after adequate alpha-blockade is established (otherwise unopposed alpha-stimulation causes paradoxical hypertension); (3) Salt and fluid loading to expand the contracted intravascular volume (catecholamine-mediated vasoconstriction causes volume depletion). This sequence is critical – initiating beta-blockade before alpha-blockade is dangerous.

Reference: Endocrine Society 2014 – Phaeochromocytoma; NICE NG136 2019