General, Breast, Endocrine Surgery

Question 1

Describe the perioperative management of carcinoid syndrome

Answer 1

Tumour derived from enterochromaffin cells and arises from different embryonic divisions of the gut

Contains membrane bound secretory granules with vasoactive substances - 5HT, Histamine, Dopamine, Substance P, Prostaglandins, Kallikrien

Their release results is symptoms of carcinoid syndrome: flushing, diarrhoea, bronchospasm, tachycardia, hypo/hypertension - A carcinoid crisis is an exaggerated form of the this syndrome.

PREOP
Assess symptoms - evidence of obstuction - RSI
diaarhoea/malabsorption - fluid assessment, check electrolytes, check for anaemia

Functional Assessment , TTE and ECG
- can cause infiltrative cardiomyopathy, or right ventricular failure.

Start octreotide infusion 50 ug/hr 12-24hrs prior to surgery (somatostatin analogue - prevents release of vasoactive substances)
- watch for SE of octreotide - bradycardia, increased Qtc

INTRAOP
- Avoid triggers of carcinoid crisis - anaesthetic depth, analgesia, normothermia, histamine releasing drugs - sux,morphine, actracurium

-Consder Regional - risk/benefit - risk of hypotension

Will need invasive monitoring and good IV access

Continue octreotide infusion - may need boluses 25-50 in crisis.

Cautious use of vasopressors - parodoxical vasodilation

POST OP
ICU for monitoring
continue octreotide - will need to be weaned
Potential for crises post op - may not have fully resected lesion