Carcinoid

 

 

 

Background

 

  • Carcinoid syndrome presents in approximately 20% of patients with carcinoid tumours, usually with hepatic metastases

  • "Carcinoid triad":

    • Carcinoid heart

    • Diarrhea

    • Flushing

  • Implicated malignancies: neuroendocrine tumors in GI tract (midgut), bronchial tumors

 

 

Considerations

 

  • Tumor: mass effect, metabolic derangements, medications, & metastases:

    • ​Mass effect: hemoptysis, bowel obstruction

    • Metabolic derangements: flushing, diarrhea, hemodynamic instability, bronchospasm (serotonin-related)

    • Medications: octreotide

    • Metastases: liver dysfunction, raised ICP if brain metastases

  • Cardiovascular dysfunction (20-40%): 

    • Right-sided valvular lesions (10% present with left-sided lesions)

    • Right ventricular dysfunction

    • Dysrhythmias (eg. SVT)

    • Constrictive pericarditis

  • Preparation & treatment of perioperative carcinoid crisis: 

    • Symptoms include flushing, diarrhea, hypotension, hyperglycemia, bronchospasm

    • Carcinoid tumors can also secrete GH (acromegaly) & ACTH (Cushing's) 

 

 

Goals

 

  • Prevent, recognize & treat perioperative carcinoid crises 

  • Triggers include: 

    • Histamine-releasing drugs, vasoactive drugs, succinylcholine 

    • Tumour manipulation

    • Hypovolemia, hypoxia, hypothermia, hypercarbia

  • Treatment of perioperative bronchospasm:

    • Avoid beta agonists, theophylline, epinephrine

    • Responds to: 

      • Octreotide

      • Steroids

      • Histamine blockade (diphenhydramine) 

      • Atrovent 

  • Prevention & treatment of carcinoid crisis:

    • Must prophylax with octreotide 300-500mcg IV 

    • During crisis: octreotide 100mcg IV boluses titrated to effect, or an infusion 

    • H1 antagonists (diphenhydramine 25-50 mg IV)

    • Refractory hypotension: 

      • Give fluids 

      • USE: octreotide, phenylephrine, vasopressin 

      • AVOID: epinephrine, norepinephrine, ephedrine 

 

 

Conflicts

 

  • RSI (bowel obstruction) vs. titrated induction

  • RSI vs. need to avoid succinylcholine 

  • Need for deep anesthesia vs. cardiovascular dysfunction

  • Bronchospasm vs. need to avoid adrenergic agents