Carcinoid syndrome for liver ablation in radiology56-year-old woman, 68 kg, for radiofrequency ablation of liver metastases under general anaesthesia in interventional radiology

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 56-year-old with metastatic midgut neuroendocrine tumour and active carcinoid syndrome, for elective liver ablation in radiology. Patient
   • Her liver deposits release serotonin into the systemic veins, so hepatic clearance is bypassed. Disease
   • Her tricuspid regurgitation is carcinoid heart disease; the lungs protect her left-sided valves.
   • Diarrhoea has dropped her potassium to 3.2; I correct it and check her fluid status.
   • Ablating tumour can set off a crisis; crises are reported during and soon after ablation. Surgery
   • Radiology is a remote site; her equipment must match theatre standards.

2. Prepare

   How will you prepare her?

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   • Her echo's right ventricular function and TR grade reviewed; repeat if it is old. Disease
   • Urinary 5-HIAA to judge how well lanreotide is controlling her syndrome.
   • Lanreotide continues; octreotide 500 mcg IV before the start, then 500 mcg/h.
   • Extra octreotide drawn up for boluses, with vasopressin and phenylephrine on the cart. Crisis
   • In radiology I check a full anaesthetic machine, monitors, capnography, suction and a trained assistant. Surgery
   • Benzodiazepine premedication, because fear and stress can trigger her mediator release. Stem trigger

3. Plan

   How will you anaesthetise her?

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   • Arterial line before induction; her pressure can swing either way within seconds. Disease
   • Propofol, fentanyl and rocuronium; no atracurium or morphine, which release histamine.
   • Adrenaline, noradrenaline and ephedrine are not my first-line pressors; catecholamines can trigger release. Stem trigger
   • Deep anaesthesia before laryngoscopy and before the probe heats, to block her sympathetic surge.
   • Measured fluids only; her right heart may already be failing. Disease
   • Ondansetron for nausea, and glucose checks, because octreotide often raises her sugar. After surgery

4. Crisis

   As the ablation starts, BP is 210/115, HR 130, and her face and chest flush. What do you do?

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   • This is a carcinoid crisis set off by the ablation; I ask radiology to stop heating. (Crisis)
   • Octreotide 50–300 mcg IV now, repeated until the surge settles.
   • Deepen her anaesthetic, since the stimulus may have outrun it.
   • If still high, a short-acting antihypertensive, titrated; I had it ready.
   • I check airway pressure; bronchospasm here gets octreotide, not salbutamol or adrenaline.

5. Crisis

   In recovery she is flushed, BP 74/40, HR 112, SpO2 95%. What now?

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   • A second crisis, now with hypotension; mediators keep coming after ablation. Crisis
   • Octreotide bolus again, with a small fluid bolus while I watch her right heart.
   • If she stays low, vasopressin or phenylephrine, not a catecholamine.
   • Her metastases still secrete, so octreotide continues after the procedure. After surgery
   • She goes to HDU or ICU, watched for further crises.