A 38-year-old man from Delhi presents with episodic severe headaches, profuse sweating, and palpitations for 3 months. Blood pressure is 168/104 mmHg. Clinical suspicion for pheochromocytoma is high. Plasma free metanephrines are elevated at 4.2 nmol/L (normal <0.9). What is the most appropriate next step in management?

Explanation

## Diagnosis Confirmed — Now Manage Hemodynamic Risk **Key Point:** Once biochemical diagnosis of pheochromocytoma is confirmed (elevated plasma free metanephrines or 24-hour urine catecholamines), the immediate next step is **pharmacological blockade** to prevent intraoperative hypertensive crisis and arrhythmias. Surgery is NOT the first step — preoperative alpha and beta blockade is mandatory. ## Preoperative Preparation Protocol 1. **Alpha-blockade first** (phenoxybenzamine 10–20 mg BD–TDS, titrate over 7–10 days) - Causes vasodilation and restores blood volume - Prevents catecholamine-induced vasoconstriction 2. **Then beta-blockade** (propranolol, atenolol) — only after alpha blockade is established - Prevents reflex tachycardia from alpha blockade - ~~Never give beta-blocker alone~~ — unopposed alpha stimulation causes hypertensive crisis 3. **Localization imaging** (CT/MRI) — performed *after* biochemical confirmation but *before* surgery **High-Yield:** The sequence is: **biochemistry → alpha-blockade → beta-blockade → imaging → surgery**. Skipping pharmacological prep increases operative mortality from 5% to 30%. ## Why This Option Is Correct Initiating alpha-blocker therapy (phenoxybenzamine) followed by beta-blocker is the **standard of care** for preoperative preparation. This prevents catecholamine-induced hypertensive emergencies, arrhythmias, and myocardial infarction during anesthesia and tumor manipulation. **Clinical Pearl:** Patients should be on adequate blockade for 7–10 days before surgery. Orthostatic hypotension during this period is expected and indicates adequate blockade. ## Timeline of Management ```mermaid flowchart TD A[Elevated plasma free metanephrines]:::outcome --> B[Initiate alpha-blockade<br/>phenoxybenzamine]:::action B --> C[After 7-10 days:<br/>Add beta-blocker]:::action C --> D[Perform CT/MRI<br/>for localization]:::action D --> E[Surgical planning<br/>& anesthesia prep]:::action E --> F[Adrenalectomy]:::action F --> G[Cure of hypertension<br/>& symptoms]:::outcome ``` **Mnemonic:** **ABCs of Pheo Prep** = **A**lpha-blocker first → **B**eta-blocker second → **C**onfirm localization → **S**urgery.