A 34-year-old woman is found to have an incidental right adrenal mass of 2.8 cm on CT abdomen. Biochemical evaluation shows 24-hour urinary metanephrines markedly elevated. She is scheduled for laparoscopic adrenalectomy. What is the most critical pharmacological step in preoperative preparation?
- A Beta-blockade with propranolol started simultaneously with alpha-blockade
- B Metyrosine alone to deplete catecholamine stores
- C Alpha-adrenergic blockade with phenoxybenzamine for at least 10–14 days ✓
- D Intravenous labetalol infusion started on the night before surgery
Correct answer: C. Alpha-adrenergic blockade with phenoxybenzamine for at least 10–14 days
Explanation
Before surgical resection of phaeochromocytoma, adequate alpha-adrenergic blockade (phenoxybenzamine or doxazosin for 10–14 days) must precede any beta-blockade to prevent unopposed alpha stimulation and hypertensive crisis. Beta-blockade is added subsequently only if tachycardia persists. Starting beta-blockade without prior alpha-blockade can precipitate severe hypertension. Metyrosine alone is insufficient. IV labetalol started the night before is too late.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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