Carcinoid crisis protocols

I just finished replying to a comment from fellow carcinoid. Our discussion was about carcinoid protocol for anesthesia.  Very important to prevent possible life endangering events during surgery or invasive procedures.

During my last chemoembolization, I had a crisis (arguably carcinoid crisis or maybe a run-of-the-mill cardiac crisis) even though the protocols mentioned below were followed.  I got a low pulse rate of 30 bpm and a too low blood pressure and spent the night in intensive care (pretty comfortable as hospital wards go, but you don’t want to need to be there). I was discharged the next morning.

This is what the National Cancer Institute of the National Institute of Health says in “Gastrointestinal Carcinoid Tumors Treatment”:

“Carcinoid crisis is manifested by profound flushing, extreme blood pressure fluctuations, bronchoconstriction, dysrhythmias, and confusion or stupor lasting hours or days and may be provoked by induction of anesthesia or an invasive radiologic procedure. This potentially fatal condition can occur after manipulation of tumor masses (including bedside palpation), administration of chemotherapy, or hepatic arterial embolization.  In contrast with the treatment of other causes of acute hypotension, the use of calcium and catecholamines should be avoided in carcinoid crisis because these agents provoke the release of bioactive tumor mediators that may perpetuate or worsen the situation. Plasma infusion and octreotide are used for hemodynamic support. For the most part, the use of somatostatin analogues has replaced other pharmacologic maneuvers in the treatment of crises, and their use has been associated with increased survival rates. Prophylactic use of subcutaneous octreotide or the administration of a depot somatostatin analogue in a timely fashion before any procedures are undertaken is mandatory to prevent the development of a crisis.”

Basically, it means that you should have subcutaneous octreotide or Sandostatin injection before the procedure or many bad things can happen. In my case some bad things happened anyway and I will have larger injections this time. My Interventional Radiologist (he told me that he has done over 400 of these procedures) says that 25% of the time some features of the crisis will occur no matter what.

What they don’t say above is that there should also be an intravenous drip of octreotide during the procedure.  This paper addresses that at length: Carcinoid/NET Cancer Specialist Rodney F. Pommier, MD on Carcinoid Crisis and Surgery. This was published just a year ago.

Also, many carcinoids can go into carcinoid syndrome if they take epinephrine.  Many anesthesia products are premixed with epinephrine so the anesthesiologist has to pick her tools carefully.  Other sites list recommended treatments for hypo and hyper blood pressure and very low heart rate that the anesthesiologist should have on hand.  Note that in the case of low blood pressure, the above document says do not use the standard treatments of calcium and catecholamines.

Simple? Straightforward? Fun?  No. No. Not at all.  But I am on a mission to inform carcinoids and the public in general of the issues that we face and that our medical practitioners need to be made aware of.

To paraphrase my brother: “Dammit Cy, why can’t you just get sick like everybody else?”

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Carcinoid crisis protocols was last modified: February 14th, 2013 by cy

8 thoughts on “Carcinoid crisis protocols

    1. It’s Larry…
      Not only interesting reading but important if I happen to be at hospital that does not treat carcinoid patients. It’s rare enough that many do not know a lot of this stuff.

  1. Any chance I could talk to you on the phone. I am experiencing certain symptoms that sound similar to carcinoid crisi and just looking for some advice

    1. Tas, I am not a doctor. If you have very low or get high blood pressure or get low or high heart rate see a doctor immediately. If you have flushing, diarrhea, etc. See a doctor, it could several different problems.
      I hope you can find the problem!

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