Question

Enumerate the objectives and measures for pre-operative optimization of a pheochromocytoma patient.

Hint:

Start alpha-blockers before beta-blockers to avoid unopposed alpha stimulation, which can worsen hypertension.

Answer 1

Step 1: Controlling Hypertension.
Patients with pheochromocytoma typically present with hypertension due to excess catecholamine secretion. The first step in pre-operative management is controlling hypertension to reduce the risk of cardiovascular complications during surgery. Alpha-blockers such as phenoxybenzamine are used to control the vasoconstriction caused by excess catecholamines.

Step 2: Managing Volume Status.
Pheochromocytoma can lead to fluid and electrolyte imbalances, particularly hypovolemia. Pre-operative measures include ensuring the patient is adequately hydrated to counteract this. Fluid resuscitation helps in improving blood volume and preventing hypotension post-surgery.

Step 3: Alpha and Beta Blockade.
Alpha-blockers (e.g., phenoxybenzamine) should be started first to prevent a hypertensive crisis. Once adequate alpha blockade is achieved, beta-blockers (e.g., propranolol) are introduced to control tachycardia and arrhythmias. This combined blockade helps in stabilizing the patient before surgery.

Step 4: Conclusion.
The goal of pre-operative optimization for a pheochromocytoma patient is to reduce the risk of cardiovascular events during surgery. Effective hypertension management, hydration, and alpha-beta blockade are crucial to achieving this.