A 44-year-old woman has episodes of pounding headache, sweating, and palpitations with BP up to 200/120 mmHg. Plasma fractionated metanephrines are markedly elevated and CT shows a 4 cm left adrenal mass consistent with pheochromocytoma. Laparoscopic adrenalectomy is planned. How should preoperative pharmacologic preparation begin?

• A Spironolactone 100 mg daily for two weeks
• B Propranolol alone started two weeks before surgery
• C Captopril titrated to normalize BP before surgery
• D Irreversible alpha blockade with phenoxybenzamine, starting several days before adding a beta blocker ✓

Explanation

Preoperative alpha blockade must precede any beta blockade. Phenoxybenzamine controls catecholamine-driven vasoconstriction and expands contracted plasma volume; beta blockade is added afterward only to manage reflex tachycardia or arrhythmias. Starting with propranolol alone risks a severe hypertensive crisis because unopposed alpha stimulation worsens vasoconstriction. ACE inhibition and mineralocorticoid antagonists do not counteract circulating catecholamines and provide no protection against intraoperative catecholamine surges.

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

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