What should be done for a patient with pheochromocytoma who wakes up with a possible hypertensive crisis?

Management of Hypertensive Crisis in Pheochromocytoma Patients

For a patient with pheochromocytoma who wakes up with a hypertensive crisis, immediate administration of intravenous phentolamine is the first-line treatment, followed by stabilization with additional alpha-blockers and supportive care. 1

Immediate Management

1. First-line medication:

   • Administer IV phentolamine (competitive alpha-blocking agent) immediately 1
   • Alternative options if phentolamine is unavailable:
     • IV nicardipine
     • IV nitroprusside

2. Additional interventions:

   • Ensure patient is in a monitored setting (ICU preferred)
   • Establish reliable IV access
   • Continuous blood pressure and ECG monitoring
   • Avoid beta-blockers alone as they can worsen hypertension by blocking vasodilation 1, 2

3. Supportive measures:

   • Consider benzodiazepines for sedation (helps reduce sympathetic outflow) 1
   • Maintain adequate hydration
   • Monitor for end-organ damage (neurological status, cardiac function, renal output)

Stabilization Phase

After initial crisis control:

1. Transition to oral medication:

   • Phenoxybenzamine (non-selective alpha-blocker) is preferred 3, 4
   • Starting dose: 10 mg twice daily, adjusting every 2-4 days as needed 5
   • Target blood pressure: <130/80 mmHg supine, >90 mmHg systolic when standing 5

2. Beta-blockade consideration:

   • Only add beta-blockers AFTER adequate alpha-blockade if tachycardia persists 5, 3
   • Premature beta-blockade can worsen hypertension due to unopposed alpha effects 2

3. Additional medications if needed:

   • Calcium channel blockers (e.g., nifedipine slow release) 5
   • Metyrosine (inhibits catecholamine synthesis) for refractory cases 5, 6

Common Pitfalls and Caveats

• Never use beta-blockers alone in suspected pheochromocytoma - can precipitate severe hypertension by blocking vasodilatory beta-2 receptors while leaving alpha-mediated vasoconstriction unopposed 1, 2

• Avoid labetalol despite its alpha/beta properties - has been associated with paradoxical hypertension in pheochromocytoma patients 1, 4

• Beware of selective alpha-1 blockers like prazosin - may be insufficient for complete blockade and can lead to hypertensive crisis 2

• Recognize the mortality risk - undiagnosed/untreated pheochromocytoma hypertensive crises carry mortality rates as high as 85% 7

• Watch for post-crisis hypotension - aggressive fluid resuscitation may be needed after catecholamine levels normalize 5

Follow-up Care

1. Definitive treatment planning:

   • Surgical consultation for adrenalectomy
   • Preoperative alpha-blockade for 10-14 days before surgery 5
   • Complete surgical resection is the mainstay of curative treatment 5

2. Diagnostic confirmation:

   • 24-hour urinary fractionated metanephrines or plasma metanephrines 1, 5
   • Adrenal imaging (CT or MRI) 5

3. Long-term monitoring:

   • Follow-up with specialized endocrinology care
   • Monitor for recurrence with periodic metanephrine testing
   • Screen for familial syndromes if indicated

Undiagnosed pheochromocytoma represents a significant anesthetic and perioperative risk 4, 7. Prompt recognition and appropriate management of hypertensive crisis in these patients is critical for preventing catastrophic outcomes including stroke, myocardial infarction, and death.