Pheo Preoperative Alpha Blockade

---
name: pheo-preoperative-alpha-blockade
description: Pre-operative preparation protocol for Pheochromocytoma, focusing on alpha-blockade titration and volume expansion. Trigger when a clinician asks "prep for pheo surgery", "alpha blockade vs beta blockade", or "doxazosin titration".
---

# Pheochromocytoma Pre-operative Alpha-Blockade

Standard preparation protocol to ensure cardiovascular stability during and after surgical resection of PPGL.

---

## Step 1 — Initiate Alpha-Adrenergic Blockade

Start **7 to 14 days** prior to surgery.

1. **Primary Agent**:
   - **Phenoxybenzamine** (Non-selective): Start 10 mg BD, titrate up by 10-20 mg every 2-3 days.
   - *Alternative*: **Doxazosin** or **Terazosin** (Selective): Start 1-2 mg daily, titrate up to 10-16 mg daily.
2. **Goal of Titration**:
   - BP < 130/80 mmHg (sitting) and > 90 mmHg SBP (standing).
   - Moderate orthostatic hypotension is a sign of achieved blockade.

 ---

## Step 2 — Initiate Beta-Blockade (ONLY second)

Start only **2-3 days AFTER** effective alpha-blockade is established.

- **Indications**: Tachycardia (HR > 100) or arrhythmias.
- **Agents**: Metoprolol, Atenolol, or Propranolol.
- **Contraindication**: NEVER start beta-blockade first (Unopposed Alpha-stimulation risk).

---

## Step 3 — Volume Expansion

Start **2 days prior** to surgery.

- **Objective**: Prevent post-resection hypotension.
- **Action**: High-sodium diet (>5000 mg/day) and increased fluid intake.
- **Inpatient**: 1-2 liters of normal saline overnight before surgery.

---

## Clinical Guardrails

- **ECG Monitoring**: Essential during titration in patients with cardiac history.
- **The Lakhani Rule**: In elderly patients or those with coronary artery disease (like Mr. Mohan), titrate more slowly and target a less aggressive BP (e.g., 140/90).

---

**Source:** Lenders JW, et al. Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline. 2014.