A 34-year-old woman with episodic palpitations, headaches and sweating has a 4 cm left adrenal mass on CT and plasma free metanephrines six times the upper limit of normal. She is scheduled for laparoscopic adrenalectomy. What is the correct preoperative pharmacological sequence?

• A Start propranolol two weeks before surgery
• B Begin amlodipine and proceed to surgery without alpha blockade
• C Give intravenous phentolamine only on induction of anaesthesia
• D Begin phenoxybenzamine first, adding a beta blocker only after adequate alpha blockade is achieved ✓

Explanation

Irreversible alpha blockade with phenoxybenzamine for 10 to 14 days preoperatively prevents intraoperative hypertensive crises. A beta blocker is added afterwards to control reflex tachycardia, never first, because beta blockade alone removes vasodilatory tone while catecholamine-driven vasoconstriction continues, provoking severe hypertension. Intraoperative phentolamine treats surges but does not replace preoperative preparation, and calcium channel blockade alone is inadequate when catecholamines are this high.

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

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Written and medically reviewed by the StethoPrep medical team.