A 45-year-old female presents with episodic palpitations, diaphoresis, and pounding headaches. Blood pressure during an episode is 210/120 mmHg. 24-hour urinary fractionated metanephrines are elevated 6-fold. Abdominal CT reveals a 4 cm left adrenal mass. Prior to adrenalectomy, what medication must be initiated FIRST to prevent fatal intraoperative hypertensive crisis?

Answer and explanation

Correct answer: C. An alpha-adrenergic antagonist (e.g., Phenoxybenzamine or Doxazosin)

  1. Step 1: The patient has a pheochromocytoma (catecholamine-secreting neuroendocrine tumor of the adrenal medulla).
  2. Step 2: Preoperative management mandates starting an alpha-adrenergic blocker (Phenoxybenzamine or Doxazosin) for at least 10-14 days prior to surgery to normalize blood pressure and expand contracted plasma volume.
  3. Step 3: Importantly, beta-blockers must NEVER be given before adequate alpha-blockade, as unopposed alpha-1 stimulation would cause catastrophic severe vasoconstriction and hypertensive crisis.
  4. Step 4: Identify alpha-adrenergic antagonist.
Answer
An alpha-adrenergic antagonist (e.g., Phenoxybenzamine or Doxazosin).
Why not the others: 'Beta-adrenergic antagonist monotherapy' is lethal because unopposed alpha-receptor vasoconstriction precipitates massive hypertensive crisis and acute pulmonary edema; 'ACE inhibitors' and 'Calcium channel blockers' are adjunctive, not the primary blockade class.

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