What is the management approach for emergency surgery in a patient with untreated pheochromocytoma?

From the Guidelines

The management of emergency surgery in a patient with untreated pheochromocytoma requires immediate preoperative preparation with alpha-adrenergic blockade for at least 10-14 days before surgery to prevent hypertensive crises and arrhythmias. This approach is based on the guidelines for the management of adrenal cancer, including pheochromocytoma, which emphasize the importance of preoperative preparation to control blood pressure and prevent complications 1. The guidelines recommend the use of non-competitive α-adrenoreceptor antagonists such as phenoxybenzamine, with a standard dose of 10 mg twice daily, and adjustments every 2-4 days to achieve blood pressure targets of <130/80 mmHg in the supine position, and systolic blood pressure preferably >90 mmHg in the upright position.

Some key considerations for the management of emergency surgery in patients with untreated pheochromocytoma include:

• Preoperative alpha-adrenergic blockade with phenoxybenzamine or doxazosine to control blood pressure
• Intraoperative management with continuous arterial pressure monitoring and readily available vasopressors and vasodilators
• Anesthesia with deep enough agents to blunt sympathetic responses, such as propofol, remifentanil, and volatile anesthetics
• Preparation for hypertensive crisis with short-acting agents like nitroprusside or nicardipine during tumor manipulation
• Postoperative monitoring for hypotension requiring fluid resuscitation and vasopressors

The goal of this approach is to minimize the risk of perioperative complications, such as hypertensive crisis, arrhythmias, myocardial infarction, and stroke, and to improve outcomes in patients with untreated pheochromocytoma undergoing emergency surgery, as highlighted in the guidelines for the management of adrenal cancer 1.

From the FDA Drug Label

Phenoxybenzamine hydrochloride capsules are indicated in the treatment of pheochromocytoma, to control episodes of hypertension and sweating. If tachycardia is excessive, it may be necessary to use a beta-blocking agent concomitantly. The management approach for emergency surgery in a patient with untreated pheochromocytoma is not directly addressed in the provided drug label. Key considerations for such a scenario would typically involve:

• Controlling blood pressure
• Managing tachycardia However, without explicit guidance from the label, no specific conclusion can be drawn regarding the exact management approach for emergency surgery in this context 2.

From the Research

Management Approach for Emergency Surgery in Untreated Pheochromocytoma

In cases of emergency surgery for a patient with untreated pheochromocytoma, the management approach is critical to prevent complications. The key considerations include:

• Preoperative preparation with alpha-adrenergic blockers to control blood pressure and prevent hemodynamic instability 3, 4
• The choice of alpha-blocker, such as phenoxybenzamine or doxazosin, depends on the patient's specific needs and the potential side effects of each medication 5, 6
• Avoidance of beta-blockers before adequate alpha-blockade is established, as this can worsen hemodynamic instability 5

Preoperative Preparation

Preoperative preparation is essential to reduce the risk of complications during emergency surgery. This includes:

• Administration of alpha-adrenergic blockers, such as phenoxybenzamine or doxazosin, to control blood pressure and prevent hemodynamic instability 3, 4
• Monitoring of blood pressure and volume status to guide fluid management and vasopressor support 4
• Consideration of the potential benefits and risks of each alpha-blocker, including the risk of postoperative hypotension 6

Intraoperative Management

Intraoperative management is critical to prevent complications during emergency surgery. This includes:

• Close monitoring of blood pressure and hemodynamic parameters to guide fluid management and vasopressor support 4
• Use of vasodilators, such as nitroprusside, to control blood pressure and prevent hemodynamic instability 4
• Avoidance of beta-blockers until adequate alpha-blockade is established, as this can worsen hemodynamic instability 5

Postoperative Care

Postoperative care is essential to prevent complications after emergency surgery. This includes:

• Close monitoring of blood pressure and hemodynamic parameters to guide fluid management and vasopressor support 4
• Management of potential side effects of alpha-blockers, such as orthostatic hypotension and edema 6
• Consideration of the potential benefits and risks of each alpha-blocker, including the risk of postoperative hypotension 6