What is the recommended perioperative pharmacologic approach to pheochromocytoma?

• A. Preoperative alpha-blockade, volume expansion, then beta-blockade if needed; avoid beta-blockers before alpha-blockade
• B. Beta-blockade first
• C. ACE inhibitors only
• D. No preoperative blockade

Answer: (A)

Blocking alpha-adrenergic effects before manipulating the tumor is the cornerstone of management. Catecholamine surges during pheochromocytoma surgery cause dangerous spikes in blood pressure primarily via alpha-1–mediated vasoconstriction, so starting with alpha-blockade blunts these surges and prevents hypertensive crises. After adequate alpha-blockade is established, expanding the intravascular volume helps counter chronic vasoconstriction and reduces the risk of postoperative hypotension once the tumor’s catecholamine input drops. If tachycardia or arrhythmias persist, a beta-blocker can be added, but only after alpha-blockade to avoid unopposed alpha activity that could worsen hypertension. Other approaches, like using ACE inhibitors alone, don’t address the acute vasoconstrictive threat, and avoiding preoperative blockade is dangerous.