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physiology

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Pheochromocytoma Resection — Anesthetic Management

α-blockade debate, intraoperative catecholamine surges, and post-ligation vasoplegia

Pheochromocytoma (PPGL) resection swings from hypertensive crisis during tumor manipulation to abrupt vasoplegia after adrenal-vein ligation; modern practice uses α-blockade (or experienced-center no-blockade), invasive monitoring, and ready vasopressin/norepinephrine infusions.

If you forget

HEADLINE: α-BEFORE-β — never β-block first; unopposed α → hypertensive crisis + pulmonary edema

Board trap

Examiner asks 'why not start with propranolol?' — Wrong: β-blockade before adequate α-blockade causes unopposed α-vasoconstriction, hypertensive crisis, and non-cardiogenic pulmonary edema. Always α first (phenoxybenzamine/doxazosin), then β only for reflex tachycardia.

Key numbers

Preop α-blockade goal: seated BP <130/85 mmHg with orthostatic drop ~15-20 mmHg
Intraop hypotension rescue: volume + norepinephrine/vasopressin in 65% of cases (DELPHI 2025)
Invasive monitoring: arterial line 88% expert consensus; CVC 68%
Functional imaging threshold: tumor >4 cm OR age ≥45 yr OR extra-adrenal OR multifocal
Vasopressin infusion: 0.01–0.04 U/min (0.6–2.4 U/hr) as adjunct when NE refractory
Phentolamine bolus: 1–5 mg IV q5 min, titrated, for intraop hypertensive surge

Reviewed Sep 24, 2026 for clinical accuracy by BoardsBridge Editorial Process

Uri Rozen, MD — Licensed Physician, Israel

Source guidelines: Endocrine Society PPGL Delphi 2025 · Endocrine Society PPGL Delphi 2025 · Endocrine Society PPGL Delphi 2025 · Endocrine Society PPGL Delphi 2025

Re-review cadence: 12 months from reviewed date.

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Card ID: pheochromocytoma-resection · Path: aba.physiology.endocrine-and-metabolic.pheochromocytoma-resection