Carcinoid syndrome

Carcinoid syndrome is caused by neoplasms from neuroendocrine cells that can release vasoactive substances such as serotonin, histamine, dopamine, substance P, prostaglandins, and kallikreins. Systemic manifestations of circulating vasoactive peptides from carcinoid tumors include flushing, wheezing, and diarrhea in addition to hemodynamic changes such as hypertension and hypotension. Carcinoid syndrome can also exacerbate cardiac and right-sided valvular problems.

Carcinoid syndrome

Anesthetic relevance
Anesthetic management	{{{anesthetic_management}}}
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Signs and symptoms
Diagnosis
Treatment
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Anesthetic implications

Carcinoid syndrome affects several organ systems that have relevance to the anesthesiologist including cardiac pathology, airway pressures, hemodynamics and electrolytes.

Preoperative optimization

• Identify signs of carcinoid-induced cardiac disease and symptoms of neuropeptide release (as well as associated triggers)
  1. 50% of patients with carcinoid syndrome develop carcinoid heart disease
  2. Consider pre-operative echocardiography to assess right heart function and tricuspid valve
  3. Octreotide therapy instituted at least 24 hours prior to surgery.
  4. Subcutaneous therapy (lanreotide) can be administered perioperatively. If the patient is inpatient, octreotide infusions can be used.
• Begin octreotide infusion at 50 μg/hr and titrate up to maximum of 200 μg/hr.

Intraoperative management

• Continue octreotide infusion at titrate up to maximum of 300 μg/hr.
• Treat with anxiolysis medication as anxiety can exacerbate vasoactive neuropeptide release.
• Avoid using medications that can cause a histamine release (morphine, meperidine, and succinylcholine)
• Bolus doses of octreotide (50-100 μg) may be necessary during induction and maintenance and if hemodynamic instability ensues

Postoperative management

• Patients will likely require intensive care unit admission for octreotide infusion and hemodynamic monitoring