A phaeochromocytoma patient is taken for laparoscopic adrenalectomy. Intraoperatively, the blood pressure rises to 240/130 mmHg during tumour manipulation. The drug of first choice is:

• A Labetalol 20 mg IV bolus
• B Esmolol infusion
• C IV metoprolol
• D Phentolamine IV bolus or sodium nitroprusside infusion ✓

Explanation

Intraoperative hypertensive crisis during phaeochromocytoma surgery is caused by catecholamine surge from tumour manipulation. The treatment of choice is an alpha-adrenergic blocker (phentolamine) or a rapidly titratable vasodilator (sodium nitroprusside). Beta-blockers (labetalol, esmolol, metoprolol) must NOT be used without prior alpha-blockade, as blocking beta-2 (vasodilatory) receptors while alpha-1 (vasoconstrictive) receptors remain unblocked leads to severe unopposed vasoconstriction and worsening hypertension. Labetalol is inappropriate as first-line because its ratio of alpha to beta blockade is insufficient.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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