Carcinoid syndrome
Stem
A 58-year-old woman, 64 kg, has a small-bowel neuroendocrine tumor with liver metastases and is scheduled for ileal resection and debulking of the liver deposits. She flushes several times a day, has chronic diarrhea, and gets a monthly long-acting somatostatin analogue injection. Her echo shows thickened, retracted tricuspid leaflets with severe tricuspid regurgitation and a mildly dilated right ventricle. Potassium is 3.2.
Question
How will you prepare her and conduct her anesthetic?
Ideal answer
HeadlineMy priority is preventing and treating carcinoid crisis, triggered by induction, stress and especially tumor handling, on a damaged right heart.
- Optimize first. I confirm the extent of her carcinoid heart disease, on this echo, and correct her potassium and dehydration from the diarrhea.1
- Octreotide bolus before induction, then an infusion. Titrated to effect, expecting more: on a long-acting analogue she may show tachyphylaxis.1
- Premedicate; arterial line before induction, central access, because stress triggers crises and pressure swings beat to beat: H1 and H2 blockers, a benzodiazepine for anxiety.
- No histamine releasers, adequate depth. No morphine or atracurium; blunting the laryngoscopy pressor response.1
- Phenylephrine or vasopressin for hypotension, not epinephrine, which can release more vasoactive peptides;1 fluid cautiously, because severe tricuspid regurgitation tolerates volume overload poorly.
Watch for: Liver handling: the surgeon warns me first; afterward a monitored bed, octreotide weaned over days.1
Breaking down the answer
- Start with the heart — carcinoid heart disease is right-sided because the lung inactivates the mediators before they reach the left side; a full preoperative cardiac workup is part of the plan.1 Saying this first shows where the real risk lies.
- Octreotide pharmacology — a somatostatin analogue that blocks hormone release; given subcutaneously it peaks at 20 to 30 minutes, with a half-life of about 60 to 90 minutes, so intraoperative dosing is IV.1
- The full avoid list — also meperidine, codeine and mivacurium; fentanyl-class opioids and non-histamine-releasing relaxants are the default.1
- Why not catecholamines — epinephrine and other catecholamines can provoke further mediator release; phenylephrine, metaraminol and low-dose norepinephrine are the listed options.1 Vasopressin is my non-catecholamine choice.
- Expect it, do not predict it — crisis is reported in about 20 to 30% of surgeries and cannot reliably be predicted, so the plan is the same for every patient with the syndrome.1
- Postoperative care — high-dependency bed while the infusion is weaned, with regional or neuraxial analgesia or PCA.1
Follow-up question
As the surgeon mobilizes the liver, her face and chest flush deeply, blood pressure falls to 62/30, heart rate rises to 128, and peak airway pressure jumps with an expiratory wheeze.
What do you do?
Follow-up answer
HeadlineCarcinoid crisis from liver handling: flushing, hypotension and bronchospasm. I tell the surgeon to stop and call for help.
Pressure first with a vasopressor, phenylephrine or vasopressin: a recent series found a vasopressor-first approach gave shorter crises and fewer aborted operations than octreotide first.2 An IV octreotide bolus goes in alongside, and I increase the infusion.1 Fluid in measured boluses, watching the right ventricle on TEE. For the wheeze I deepen the anesthetic and avoid epinephrine. Anaphylaxis stays on my differential; I check the timing against recent drugs. I reassess pressure, airway pressures and glucose, and agree with the surgeon when to resume.
Pitfalls that cost points
- Reaching for epinephrine or ephedrine as first-line pressors.
- Assuming her monthly long-acting injection is enough cover for surgery.
- Stopping the octreotide at the end of the case.
Rapid-fire
Q: Why does carcinoid heart disease spare the left side? A: The lung inactivates serotonin and other mediators, so left-sided disease suggests an intracardiac shunt or a bronchial primary.
Q: What triggers a crisis apart from handling the tumor? A: Anxiety and stress, anesthesia, hypothermia and certain drugs.1
Q: Why might she need more octreotide than expected? A: Patients on long-acting analogues can develop tachyphylaxis and need higher doses during surgery.1
Q: Which receptors does octreotide act on? A: Somatostatin receptor subtypes 2, 3 and 5 on the tumor.1
Numbers to know
| Item | Value |
|---|---|
| Octreotide bolus and infusion | No agreed regimen; published doses vary widely, so titrate to effect1 |
| Subcutaneous peak | 20–30 min1 |
| Half-life | ~60–90 min1 |
| Crisis frequency | ~20–30% of surgeries1 |
Links
- Vasopressors and inotropes: choosing and titrating, Intraoperative hypotension: differential and management, Intraoperative bronchospasm, Pulmonary hypertension and right ventricular failure, anaphylaxis
- Atlas: Basic valvular lesions on 2D and color
- ENETS consensus guidelines on perioperative therapy in neuroendocrine tumors
Sources
- 1.Carcinoid Crisis and Anaesthesia · NeuroEndocrine Cancer Australia · neuroendocrine.org.auPatient-organization fact sheet for the treatment team: drugs to avoid, vasoconstrictor choice. Its octreotide range (100–1000 mcg bolus and mcg/h) is wider than many published regimens, so the page gives no fixed dose.
- 2.Comparison of Octreotide and Vasopressors as First-Line Treatment for Intraoperative Carcinoid Crisis · Ann Surg Oncol 2024;31(5):2996-3002 (McCully, Kozuma, Pommier, Pommier), 2024 · ohsu.elsevierpure.comRetrospective database study; read as the published abstract. Octreotide-first protocols had longer crises and more aborted operations than vasopressor-first.
Facts on this page were checked against these sources on Oct 16, 2026. Guidelines change; confirm doses against current institutional protocols.