Anesthesia for Carcinoid Syndrome

Carcinoid Syndrome

Carcinoid syndrome is the complex of symptoms and signs caused by the secretion of vasoactive substances (eg, serotonin, kallikrein, histamine) from entero-epinephrine tumors (carcinoid tumors). Because most of these tumors are located in the gastroin-testinal tract, their metabolic products are released into the portal circulation and destroyed by the liver before they can cause systemic effects. However, the products of nonintestinal tumors (eg, pulmonary, ovarian) or hepatic metastases bypass the portal cir-culation and, therefore, can cause a variety of clini-cal manifestations. Many patients undergo surgery for resection of carcinoid tumors; most such patients have not experienced carcinoid syndrome.

Clinical Manifestations

The most common manifestations of carcinoid syndrome are cutaneous flushing, bronchospasm, profuse diarrhea, dramatic swings in arterial blood pressure (usually hypotension), and supraventricu-lar arrhythmias (Table 34–9). Carcinoid syndrome is associated with right-sided heart disease caused by valvular and myocardial plaque formation, and, in some cases, implantation of tumors on the tricuspid and pulmonary valves. The diagnosis of carcinoid syndrome is confirmed by detection of serotonin metabolites in the urine (5-hydroxyin-doleacetic acid) or suggested by elevated plasma lev-els of chromogranin A. Treatment varies depending on tumor location but may include surgical resec-tion, symptomatic relief, or specific serotonin and histamine antagonists. Somatostatin, an inhibitory peptide, reduces the release of vasoactive tumor products.

Anesthetic Considerations

The key to perioperative management of patients with carcinoid syndrome is toavoid anesthetic and surgical techniques or agents that could cause the tumor to release vasoactive substances. Regional anesthesia may limit release of stress hormones perioperatively. Large bolus doses of histamine-releasing drugs (eg, morphine and atracurium) should be avoided. Surgical manipu-lation of the tumor can cause a massive release of hormones. Monitoring likely will include an arterial line. If there are concerns about hemodynamic insta-bility or intrinsic heart disease caused by carcinoid syndrome, transesophageal echocardiography may be helpful. Alterations in carbohydrate metabolism may lead to unsuspected hypoglycemia or hypergly-cemia. Consultation with an endocrinologist may help clarify the role of antihistamine, antiserotonin drugs (eg, methysergide), octreotide (a long-acting somatostatin analogue), or antikallikrein drugs (eg, corticosteroids) in specific patients.