MeowMix

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[disclaimer: third-year student here, sorry if I sound like a novice, I am]

We have a 21 yo guy on our surgery service who got an emergency small bowel resection for trauma 3 d ago. He has been hypertensive, tachycardic and nauseous ever since his operation, but non-febrile. His past medical history was zero except for appendectomy 2 m ago. We have been at a dead end until today, when he casually mentioned that he got the appendectomy because he had a carcinoid tumor. :eek: Now that we have this useful piece of information, his symptoms fit well with excess serotonin etc. and carcinoid syndrome.

How would you approach a patient like this for anesthesia, if we had to do anything else with him? Also, what about anti-emetics and pain meds post-op?

thanks
 

InductionAgent

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MeowMix said:
[disclaimer: third-year student here, sorry if I sound like a novice, I am]

We have a 21 yo guy on our surgery service who got an emergency small bowel resection for trauma 3 d ago. He has been hypertensive, tachycardic and nauseous ever since his operation, but non-febrile. His past medical history was zero except for appendectomy 2 m ago. We have been at a dead end until today, when he casually mentioned that he got the appendectomy because he had a carcinoid tumor. :eek: Now that we have this useful piece of information, his symptoms fit well with excess serotonin etc. and carcinoid syndrome.

How would you approach a patient like this for anesthesia, if we had to do anything else with him? Also, what about anti-emetics and pain meds post-op?

thanks
Preoperatively, Octreotide (somatostatin) is the primary treatment of the serotonin excess. Carcinoids can also secrete histamine, so also consider diphenhydramine. And of course, make sure he's not taking SSRIs, TCAs, tramadol or any other drugs that can exacerbate the serotonin syndrome,

For anti-emetics, a serotonin antagonist like ondansetron would seem especially appropriate

For post-op pain, as mentioned above, don't use tramadol. A fentanyl-like opioid would be preferable to morphine, which can cause histamine release.
 
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MeowMix

MeowMix

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Thanks for the info.

Ondansetron appears not to work at all well in this guy; promethazine seems to be more effective. He turned purple on fentanyl in the air ambulance, and definitely does not do well on morphine. It's helpful to be able to understand his responses better now, with your info and knowing the underlying condition.
 
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UTSouthwestern

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MeowMix said:
Thanks for the info.

Ondansetron appears not to work at all well in this guy; promethazine seems to be more effective. He turned purple on fentanyl in the air ambulance, and definitely does not do well on morphine. It's helpful to be able to understand his responses better now, with your info and knowing the underlying condition.
Try granisetron/Kytril 40 micrograms/kg up to one milligram. Mean duration of action of 8 hours but as long as 18 hours in some patients. I used it on my cancer patients in internal medicine including some with carcinoid, with great effect. It's expensive though, about $100/day.
 

Noyac

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UTSouthwestern said:
Try granisetron/Kytril 40 micrograms/kg up to one milligram. Mean duration of action of 8 hours but as long as 18 hours in some patients. I used it on my cancer patients in internal medicine including some with carcinoid, with great effect. It's expensive though, about $100/day.

IMHO Kytril SUCKS ass.
But that may be just in my hands.
 

militarymd

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Noyac said:
IMHO Kytril SUCKS ass.
But that may be just in my hands.
it's supposed to be given IV....not PR (per rectum)
 

seattledoc

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I thought that carcinoid tumors of the gut typically weren't symptomatic because the liver would effectively remove the seretonin, histamine, kinins etc.
Carcinoid syndrome that you're describing occurs when there are liver mets or tumors in non-GI places (lung usually I think).
 

UTSouthwestern

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Noyac said:
IMHO Kytril SUCKS ass.
But that may be just in my hands.
Problem is that the OR usually has the most dilute form (0.1 mg/cc, 1 cc vial). 40 ug/kg for a 100 kg person is 4 mg. No one is going to break 40 vials to get the therapeutic dose for a patient.
 
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seattledoc said:
I thought that carcinoid tumors of the gut typically weren't symptomatic because the liver would effectively remove the seretonin, histamine, kinins etc.
Carcinoid syndrome that you're describing occurs when there are liver mets or tumors in non-GI places (lung usually I think).
You are correct. We think that he probably has mets to the liver (or a non-GI primary), which he did not know about. His appy was 2 m ago and the excess serotonin etc. from that primary should be long gone from his system, so something else is probably causing this reaction.
 

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UTSouthwestern said:
Problem is that the OR usually has the most dilute form (0.1 mg/cc, 1 cc vial). 40 ug/kg for a 100 kg person is 4 mg. No one is going to break 40 vials to get the therapeutic dose for a patient.

Yes, I know. They package it in 0.1mg doses and say that its cheaper than zofran and anzemet. I began to give 3-4 vials at a time and only charged the pt for one. It still wasn't as good as zofran or even anzemet for that matter. But now its 3 times the cost.
 

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Noyac said:
Yes, I know. They package it in 0.1mg doses and say that its cheaper than zofran and anzemet. I began to give 3-4 vials at a time and only charged the pt for one. It still wasn't as good as zofran or even anzemet for that matter. But now its 3 times the cost.
Just give 40 vials of it and you have long term Zofran. Simple. :thumbup: It does work however, with the right dosage.
 

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in addition to above posters you can always do the following to minimize post op nausea and vomiting:

go low on the narcs
run propofol/nitrous vs volitile/nitrous
scopolomine patch
decadron 8-10mg
reglan (perhaps some clinically releventcentral anti-dopaminergic effect on the CRZ)
throw down and og and suck all the crap outta this guys gut
tank em up with the fluids


dunno about kytril, never touched the stuff. I rarely use zofran however. Try and reserve that 16 buck per vial drug for at risk N/V outpatients.
 

seattledoc

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If you're running propofol instead of potent agent you could just as well pop the top off the zofran and be done with it. It'll cost less in the long run. And I would say skip the N2O if you have a confirmed puker.
 

Noyac

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VentdependenT said:
in addition to above posters you can always do the following to minimize post op nausea and vomiting:

go low on the narcs
run propofol/nitrous vs volitile/nitrous
scopolomine patch
decadron 8-10mg
reglan (perhaps some clinically releventcentral anti-dopaminergic effect on the CRZ)
throw down and og and suck all the crap outta this guys gut
tank em up with the fluids


dunno about kytril, never touched the stuff. I rarely use zofran however. Try and reserve that 16 buck per vial drug for at risk N/V outpatients.
This is a good approach, Venti. But I will make 2 comments b/c thats how I am. One: I use as much narc's as needed to keep resp. rate around 12/min even in the pukers. Thats b/c pain will also make one puke. Two: I would skip the nitrous all together even in TIVA.
 

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MeowMix said:
[disclaimer: third-year student here, sorry if I sound like a novice, I am]

We have a 21 yo guy on our surgery service who got an emergency small bowel resection for trauma 3 d ago. He has been hypertensive, tachycardic and nauseous ever since his operation, but non-febrile. His past medical history was zero except for appendectomy 2 m ago. We have been at a dead end until today, when he casually mentioned that he got the appendectomy because he had a carcinoid tumor. :eek: Now that we have this useful piece of information, his symptoms fit well with excess serotonin etc. and carcinoid syndrome.

How would you approach a patient like this for anesthesia, if we had to do anything else with him? Also, what about anti-emetics and pain meds post-op?

thanks
I would confirm that he has carcinoid syndrome, before going down that path. He may have had a carcinoid tumor without the carcinoid syndrome. It sound like it's likely, but still better to confirm before treating empirically.
 

lvspro

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It's funny that carcinoid is coming up on this board. I had no less than 10 questions on carcinoid syndrome on my inservice exam on sat.
 

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Drug wise, some other methods of treating PONV that I have seen besides those mentioned include small doses of Haldol like 1-2 mg, or even a very small dose of propofol like 2-5mcg/kg/min have worked for me. These are of course way down in the arsenal.
 
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