A 40-year-old woman is evaluated for episodic hypertension, diaphoresis, and headache. 24-hour urine metanephrines are 4× the upper limit of normal. CT shows a 4 cm right adrenal mass. After adequate alpha-blockade with phenoxybenzamine for 2 weeks, surgery is planned. Which is the most appropriate intraoperative maneuver when the adrenal vein is ligated?

• A Anticipate hypertensive crisis; have phentolamine ready
• B Administer high-dose glucocorticoid immediately after ligation
• C Rapid fluid restriction to prevent circulatory overload
• D Anticipate profound hypotension; have norepinephrine infusion ready ✓

Explanation

After ligation of the adrenal vein during pheochromocytoma resection, there is a sudden drop in circulating catecholamines leading to profound hypotension. This is expected and requires intravenous fluid boluses and vasopressor (norepinephrine) support. Preoperative alpha-blockade prevents intraoperative hypertensive surges during tumor manipulation. High-dose glucocorticoid is relevant only in bilateral adrenalectomy for adrenocortical insufficiency.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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