Ppgl Preoperative Salt Saline Protocol

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name: ppgl-preoperative-salt-saline-protocol
description: Implements preoperative salt loading and saline infusion to prevent orthostatic hypotension and hemodynamic instability during PPGL surgery. Initiates normal salt diet (9 g/day) on day 3 of alpha-blockers and administers 1-2 L saline infusion from evening before surgery until surgery for patients scheduled for PPGL surgical resection, completing preoperative alpha-blocker titration, or preventing intraoperative hypotension in PPGL surgery.
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# Preoperative Salt and Saline Infusion Protocol for PPGL

## STEP 1 — Gather Information
Confirm PPGL diagnosis, surgical scheduling, current alpha-blocker regimen and titration status, baseline blood pressure, orthostatic vitals, and signs of volume depletion; review cardiac and renal function for fluid safety.

## STEP 2 — Rule In / Rule Out
Rule in if patient has biochemically or imaging-confirmed PPGL, is scheduled for surgical resection, and is on or completing preoperative alpha-blocker titration; rule out if any criterion is missing.

## STEP 3 — Classify or Stratify
Assess for orthostatic hypotension (systolic drop ≥20 mmHg or diastolic ≥10 mmHg on standing) and blood pressure control; if present, prioritize salt loading; if absent, proceed with standard salt diet.

## STEP 4 — Decide
Initiate normal salt diet (9 g/day) starting on day 3 of alpha-blocker therapy; administer 1–2 L isotonic saline infusion from the evening before surgery until surgery to expand plasma volume.

## Clinical Guardrails / Mimics / Pitfalls
Do not start salt loading before day 3 of alpha-blockers (may exacerbate hypertension); avoid excessive salt in patients with decompensated heart failure or severe renal impairment; monitor for pulmonary edema during saline infusion; do not replace individualized blood pressure goals with protocol alone.

## Concrete Clinical Example
A 52-year-old with adrenal PPGL on day 2 of phenoxybenzamine 10 mg BID, BP 138/86 mmHg, no orthostatic symptoms, scheduled for laparoscopic adrenalectomy tomorrow; start 9 g/day salt diet today (day 3) and begin 1.5 L saline infusion tonight.

**Source:** Japan Endocrine Society Clinical Practice Guideline for the Diagnosis and Management of Pheochromocytoma and Paraganglioma 2025, Japan Endocrine Society, 2025, DOI: 10.1507/endocrj.EJ25-0165