Carcinoid
Background
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Carcinoid syndrome presents in approximately 20% of patients with carcinoid tumours, usually with hepatic metastases
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"Carcinoid triad":
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Carcinoid heart
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Diarrhea
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Flushing
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Implicated malignancies: neuroendocrine tumors in GI tract (midgut), bronchial tumors
Considerations
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Tumor: mass effect, metabolic derangements, medications, & metastases:
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Mass effect: hemoptysis, bowel obstruction
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Metabolic derangements: flushing, diarrhea, hemodynamic instability, bronchospasm (serotonin-related)
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Medications: octreotide
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Metastases: liver dysfunction, raised ICP if brain metastases
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Cardiovascular dysfunction (20-40%):
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Right-sided valvular lesions (10% present with left-sided lesions)
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Right ventricular dysfunction
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Dysrhythmias (eg. SVT)
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Constrictive pericarditis
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Preparation & treatment of perioperative carcinoid crisis:
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Symptoms include flushing, diarrhea, hypotension, hyperglycemia, bronchospasm
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Carcinoid tumors can also secrete GH (acromegaly) & ACTH (Cushing's)
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Goals
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Prevent, recognize & treat perioperative carcinoid crises
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Triggers include:
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Histamine-releasing drugs, vasoactive drugs, succinylcholine
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Tumour manipulation
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Hypovolemia, hypoxia, hypothermia, hypercarbia
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Treatment of perioperative bronchospasm:
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Avoid beta agonists, theophylline, epinephrine
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Responds to:
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Octreotide
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Steroids
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Histamine blockade (diphenhydramine)
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Atrovent
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Prevention & treatment of carcinoid crisis:
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Must prophylax with octreotide 300-500mcg IV
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During crisis: octreotide 100mcg IV boluses titrated to effect, or an infusion
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H1 antagonists (diphenhydramine 25-50 mg IV)
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Refractory hypotension:
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Give fluids
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USE: octreotide, phenylephrine, vasopressin
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AVOID: epinephrine, norepinephrine, ephedrine
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Conflicts
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RSI (bowel obstruction) vs. titrated induction
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RSI vs. need to avoid succinylcholine
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Need for deep anesthesia vs. cardiovascular dysfunction
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Bronchospasm vs. need to avoid adrenergic agents