Pre-operative preparations for a patient undergoing surgery for phaeochromocytoma primarily focus on stabilising cardiovascular status and minimising perioperative risks associated with catecholamine surges.
Firstly, adequate alpha-adrenergic blockade is essential to control hypertension and prevent intraoperative hypertensive crises. This is typically achieved with non-selective alpha-blockers such as phenoxybenzamine, started 10-14 days before surgery to allow blood pressure and volume expansion to stabilise NICE CKS.
Following alpha-blockade, beta-blockers may be introduced cautiously to control tachycardia, but only after adequate alpha-blockade to avoid unopposed alpha-adrenergic receptor stimulation which can worsen hypertension NICE CKS.
Volume expansion with intravenous fluids or high-salt diet is recommended preoperatively to correct chronic volume contraction caused by catecholamine excess, reducing the risk of postoperative hypotension Lenders et al. 2020.
Preoperative biochemical confirmation and localisation of the tumour are mandatory to guide surgical planning and anticipate intraoperative challenges NICE CKS. Genetic testing may also be considered to identify hereditary syndromes influencing management Lenders et al. 2020.
Close cardiovascular monitoring and optimisation of any comorbidities, including arrhythmias and heart failure, are important to reduce perioperative morbidity NICE CKS.
In summary, the key preoperative steps include initiating alpha-adrenergic blockade well in advance, cautious beta-blockade if needed, volume repletion, thorough biochemical and imaging assessment, and cardiovascular optimisation to ensure safe surgical outcomes NICE CKS; Lenders et al. 2020.
Key References
- CKS - Cushing's syndrome
- NG132 - Hyperparathyroidism (primary): diagnosis, assessment and initial management
- CKS - Hypercalcaemia
- CKS - Hyperthyroidism
- CKS - Hypertension in pregnancy
- (Domi and Laho, 2012): Management of pheochromocytoma: old ideas and new drugs.
- (Lenders et al., 2020): Genetics, diagnosis, management and future directions of research of phaeochromocytoma and paraganglioma: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension.