A 38-year-old woman presents with episodic headaches, sweating and palpitations. 24-hour urine metanephrines are markedly elevated. CT abdomen shows a 4 cm right adrenal mass. Which is the MOST important pre-operative preparation step before surgical resection?
- A Start a beta-blocker first to control heart rate
- B Start an alpha-blocker (phenoxybenzamine or doxazosin) for at least 10–14 days before surgery ✓
- C Start metyrapone to reduce catecholamine synthesis
- D Proceed directly to surgery as the mass is operable
Correct answer: B. Start an alpha-blocker (phenoxybenzamine or doxazosin) for at least 10–14 days before surgery
Explanation
Alpha-adrenergic blockade must be established for a minimum of 10–14 days before surgery to prevent hypertensive crisis during tumor manipulation. Phenoxybenzamine (non-competitive) or selective alpha-1 blockers (doxazosin, prazosin) are used. Beta-blockers are added only after alpha-blockade is achieved; starting beta-blockers first causes unopposed alpha stimulation and severe hypertension. Metyrapone blocks cortisol synthesis and is used in Cushing's, not pheochromocytoma.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.