EDITOR:

We thank Dr Fassam for his interest in our study and his comments [Reference Alper, Taydaş and Ulukaya1]. We agree with him that the use of beta blockers is not a favourable option and has limited indications during arrhythmias in case of phaeochromocytoma. In our case, during surgery both beta-blocker drugs were selected to control aggravated hypertension of the patient who had regulated hypertension before surgery. The diagnosis of phaeochromocytoma was not suspected at that time. So we agree with Fassam that beta blockers, unfortunately, might have contributed to the severity of hypertensive attacks. The other recommended agent phentolamine, a short-acting alpha blocker, could not be used due to unavailability in our institution during this case.

Magnesium sulphate is routinely used to control arrhythmias and hypertension in patients undergoing cardiovascular surgery and in the Caesarean section of preeclamptic patients or ICU patients. However, magnesium sulphate is not the first drug of choice to control hypertension in other surgical procedures. First a vasodilatory drug treatment including nitroglycerine, nitroprusside, calcium-channel-blockers or beta blockers is started and subsequently other adjuvant drugs are added according to the features of the cardiovascular status of the hypertensive patients and even in some patients with phaeochromocytoma as reported by Fassam in reference 4 [Reference James and Cronje2]. It appears that questions concerning the appropriate management of patients with phaeochromocytoma during surgery are increasing. In reference 4 sited by Fassam, all patients were given isoflurane. However, isoflurane was inadequate to attenuate their arterial hypertension. Hence it is not superior to propofol in this aspect and may even have a negative effect to prevent intracranial pressure increase in severe hypertensive crises. In our case, single bolus following infusion of propofol dramatically decreased arterial pressure. The effect of propofol on blood pressure seems to be an additive effect to vasodilator treatment used previously. We agree about the comments on magnesium sulphate. If we consider the effects of propofol and magnesium sulphate on the cardiovascular system, a further choice might be the combination of propofol and magnesium sulphate to manage hypertensive crisis of patients having phaeochromocytoma, perhaps without alpha blocker treatment. A better attenuation of cardiovascular responses can be obtained because of their potentiation of each other.