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Carcinoid case

Discussion in 'Anesthesiology' started by trinityalumnus, May 8, 2007.

  1. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    As usual, my Wednesday assignment is a liver and bowel resection for carcinoid. This surgeon gets referrals from literally all over the country.

    The routine hemodilution technique has me drawing off two units of blood (replacing with crystalloid) and storing on ice until the bloody dissection is done (many hours later), then giving it back. I usually don't think twice about it, but last week:.........

    Pt was a 73 little ole lady with h/o CABG in 2003, stented in 2006, with cardiologist clearance. Needs SL NTG with activity routinely. Preop crit was 34, and the BUN/creatinine ratio was almost 10:1. I felt reasonably confident it was a dry crit.

    I really didn't want this lady's crit to drop below 30 given her history. I felt her real non-dry crit was probably closer to the upper 20s which perhaps is not a good starting point to draw off two units. Anyway, surgeon asks me as usual to hemodilute as he's making skin incision. We discuss it and he agrees I can wait until we get some fluid in. After one hour (abdomen is now open) and one liter her crit per I-stat is 27.

    Would you have drawn off two units?

    To the med students: can't use ephedrine or epi on these cases. Why?
     
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  3. InGasWeTrust

    InGasWeTrust Member
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    Trinityalumnus,

    I know you think you have a lot to offer, and truth is you prolly have a nice clinical cume of knowledge and pearls. But before you start spouting off at the lip to teach medical students and residents you must realize that we really DONT care what you have to say. Unless you are a BOARD certified anesthesiologist I dont really care to "chop" it up with you or other CRNA's regarding clinical matters.


    I have nothing personal against you, but you must realize that despite how many nurses feel, anesthesiology is and continues to remain a medical specialty. I know that you are trying to help, and kudos to you, but please do not think for a second that your input is valued beyond mere clinical experience.
     
  4. VolatileAgent

    VolatileAgent Livin' the dream
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    hemodilution is passe. although rare presenters, i've actually done a couple of carcinoid cases in residency - but not using this technique - and both without problem. you just gotta pay extra attention when they start to manipulate the tumor. now, pheos... those are real fun!
     
  5. SouthSideSteve

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    You can always learn from people regardless of their title. I was under the impression trinity was an MD. Pretty arrogant post above as to think you can't learn from someone just because of their title.
     
  6. coccygodynia

    coccygodynia Member
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    Speak for yourself - you can learn something from anyone, no matter what letters follow their name.
     
  7. InGasWeTrust

    InGasWeTrust Member
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    I know, I know, everyone can teach something, that is NOT my point.


    Imagine for a second that CRNA's were chairs of our residency programs, that your attending is a CRNA, you see it starts getting ridiculous.

    Reread my post carefully and you will get the thrust of my post which was not to bash/flame trinityalumnus but to enlighten him on my feelings as a resident about "teaching" me information.

    The thing that most CRNAs can really teach well in general is good charting, they are taught early on about charting everything and how to do it accurately. Unfortunately I have been witness to some nightmare charting done by a few of my resident collegues.

    See I am not so close minded afterall
     
  8. Noyac

    Noyac ASA Member
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    InGas, all I can say is that you have a long road ahead of you.

    As far as the case, I don't think that is a dry crit. Her BUN/CR is 10:1. Not 20:1.
    I too have done quite a few of these cases and I never did the hemodilution thing. I did however, start the PRBC's just b/4 the blood letting from time to time. And carcinoid + indirect pressors or epi = bad combo.

    Neo baby.
     
  9. zippy2u

    zippy2u Senior Member
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    Hemodilution, sevodilution, tevodilution. What are ya dealin' with, one of those Jehovah squirrels? If ya worried about blood loss tell em to use the cell saver and get your PRBCs(homologous) from the blood bank. I've never done hemodilution in the private sector. Tell the surgeon ya can't do it because you'll lower her O2 carrying capacity that may precipitate a PCE( perioperative cardiac event). ----Regards, ----Zippy
     
  10. irie

    irie royale with cheese
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    Can you expand on this just for my sake?
     
  11. Planktonmd

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    Hemodilution should never be done on a patient with coronary artery disease, period!
    Also, by hemodiluting, you are lowering the hematocrit while maintaining the CVP which goes against what you want to do in liver dissection.
    In this patient your intraop management should focus on keeping the Hematocrit normal and avoiding hypotension and tachycardia, you could also allow the CVP to drift down a little by delaying crystaloid replacemnt, a low CVP wolud decrease the bleeding from the dissected liver and help you decrease blood loss more than hemodilution.
    Cell saver is not a good idea in a Carcinoind case.
     
  12. rmh149

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    Noyac, correct me if I am wrong.

    Carcinoid tumors can secret serotonin and histamine and other hormones...presents with flusing, bronchoconstricion, hypotension or hypertension.

    catecholamines can evoke serotonin release.

    Although, octreotide...100-200mcg IVP can be given to treat carcinoid crisis introperatively....

    Even though neosynephrine is my drug of choice I dont think I would completely avoid ephedrine. glycopyrrolate and ephedrine would my choice of drugs to treat bradycardia (if its an issue)....especially after octreotide.

    Post-operatively I would consider using a fentanyl PCA vs MSO4 or demerol due to the potention problems from histamine release.

    As far as hemodiluting the patient below HCT of 30 on a patient with CAD....I suppose it depends on how risky you want to get that day. I dont really have an opinion on that because I have never been asked to do this....thank goodness. Although my first impression is its not a good idea given she needs nitro SL daily.

    Again....anesthesia is outcome driven.

    How did it go?
     
  13. zippy2u

    zippy2u Senior Member
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    Plankton, Thanks for correcting me.... yeah, the cell saver and carcinoid or malignancy is prolly not a good idea. Thanks again for catching that mistake. ----Regards, ---Zip
     
  14. Noyac

    Noyac ASA Member
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    These typically are GI tumors w/c we all know. THey are usually not that big of a deal since the portal circulation metabolizes the released vasoactive substances. Except when the liver is involved as in this case. Yes they release serotonin and histamine as well as kallikrien. You want to avoid hypotension mostly, w/c cause the hormone release. If you give catecholamines (or indirect vasopressors w/c work by releasing catechols) you may cause the release of kallikrien. Kallikrien causes vasodilation and bronchoconstriction. Therefore, direct agents are better IMHO.

    Yes, avoid anything that will lead to histamine release, ie:MS.
     
  15. hudsontc

    hudsontc Attending
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    Trinity,
    Thank you for posting--that's a good case and it's threads like this that keep me coming back to this site.

    My one qualm with anesthesia so far has been the distorted and fear-driven perspectives propagated on this site. I hate it.
     
  16. VolatileAgent

    VolatileAgent Livin' the dream
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    yes. this is true. in the cases i did, one stomach and one small bowel, the surgeons ligated the vascular supply without disturbing the tumor itself prior to its removal. the patient's bp never even blipped. oh, at the time of the first one, i was definitely tight sphincter-toned and ready for some serious hemodynamic hijinks... ah, the good ole days of ca-1... :laugh:

    now, the adrenal pheo i recently did in an otherwise healthy 23-year-old female... that was a roller coaster ride...
     
  17. rmh149

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    Well, since you brought it up. :)

    What drugs did you use to control BP with your pheo case?
     
  18. VolatileAgent

    VolatileAgent Livin' the dream
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    everything. :laugh:

    seriously, during certain points in this case this girl's blood pressure went from 80/50 with a heartarte of 65 one minute, then to 220/140 with a heartrate of 140 the next. it was a true roller coaster.

    the procedure was done laparoscopically. patient was positioned on her side with a soft kidney-break in the table. we lined her up with art line and double-lumen IJ. i was iffy on the IJ, but my attending wanted it so we put it in. his rationale was that, if you were going to have a massive sympathetic charge, you want to be able to dump counter-active substances directly onto the heart. this seemed reasonable.

    now, pre-operatively, this girl was an otherwise healthy athletic type 23-year-old. contrary to popular and standard training, she was not given phenoxybenzamine pre-operatively. the surgeons working her up used a cocktail of amlodipine and terazosin. their rationale was that once you remove the tumor you still have the phenoxybenzamine on-board, and that this can complicate the post-op course. her pretreatment with the aforementioned drugs went on for about a month, with escalating doses, prior to the procedure. she also had started low dose metoprolol (12.5 bid) about two weeks prior.

    despite all of this, she was still relatively orthostatic in the pre-op area. we opted for a thoracic-level paravertebral block for the operative side at the t10 level. she was tanked up with additional fluids, and we started an low-dose esmolol drip prior to induction. pre-operatively her BP, iirc, was in the 120-140/60-90 range with a HR around 100. we also started an art-line in the pre-op area, which she tolerated well.

    getting her in the OR, on the table, induced, and positioned was relatively easy and without problem. after all, she was a healthy young college-aged kid. the real fun started with the incision when they inserted the trocars and just started to manipulate things out of the way. this is when her BP and pulse went haywire. i swear, even looking at that adrenal gland made her SBP jump 60mmHg. basically, she got esmolol and phentolamine (which i'd never used before) boluses during these parts of the case because, when not stimulated, her BP would drop pretty precipitously. the key was careful observation of how the surgical procedure was progressing, and direct discussion with the surgeons about when they were going to be getting near the tumor or manipulating the adrenal gland.

    post-operatively, i went and saw her in the SICU that evening. she actually did amazingly well, and the paravertebral catheter had worked very well for her post-op pain. she was wide awake and had been very stable in the post-op timeframe. all in all, i'd say i gave her roughly 5L of fluid (starting in the pre-op area) for what was about a 1.5 hour case. they d/c'd the art-line post-op, the central line the next day, the paravertebral the day after that, and from what i'd heard from one of my surgery resident colleagues she went home after about three days.
     
  19. rmh149

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    Very nice. I especially like the paravertebral block...makes for a beautiful non-narcotic post-operative experience.

    Being that I am not well experienced with paravertebral blocks (can see myself on www.nysora.com just before surgery), would a lumbar epidural with just a narcotic infusion work for post op pain control, being that this was a laparascopic procedure?

    Phentolamine! Very interesting. I have not heard of that drug since I was in school. I would have thought NTG or Nipride coupled with the esmolol drip. However, blocking the Alpha adrenergic receptors with phentolamine and B-1 with esmolol makes total sense. Did you run a drip or IV push the phentolamine? I think I would have some NTG diluted in a 30cc syringe just in case...due to my insecurity with a drug i have not had much experience with.

    Also, did the duration of action of phentolamine mimic the duration of endogenous release of catecholamines?

    Thanks for the post.
     
  20. VentdependenT

    VentdependenT You didnt build thaT
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    What the.....you make no sense man.

    Thanks for the clinical hit trin
     
  21. YupGypsy

    YupGypsy Banne*d for Tr*olling
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    trinity is the only CRNA that makes sense here.
     
  22. rmh149

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    Thanks ;) . Im such a loser.
     
  23. YupGypsy

    YupGypsy Banne*d for Tr*olling
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    maybe you should try harder
     
  24. jetproppilot

    jetproppilot Turboprop Driver
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  25. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    Thanks to everyone for their input on this case. Forgot to add my lazy-man technique for these multihour cases where I'm reasonably confident we're not extubating. Preface:

    1. hospital doesn't carry precedex
    2. epidural was not performed (I suggested)

    So ..... while this certainly isn't Nobel prize worthy, I love to do long cases under those circumstances with nimbex and fentanyl on constant infusion pump. Takes all of five extra minutes to set up, and just makes life easier throughout the day.
     
  26. fakin' the funk

    fakin' the funk ASA Member
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    Not that I like being pimped by a nurse, but...

    Did we answer this question?
     
  27. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    If you choose to read above and not just skimp
    You'll find the answer to the question posed by the pimp
    Check post number eleven and even thirteen
    So in the OR you'll look lean and mean

    Pimp Daddy Masta Blasta
     
  28. swpm

    swpm Now with extra snarkiness
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    The only thing worse than being pimped by a nurse is being pimped by a nurse who rejects your correct answer and "teaches" you something incorrect.

    I was floating a Swan a couple months ago and the nurse in the room actually pimped me about the determinants of mixed venous O2 sats. It was awkward. I thought about ignoring her but figured that would be rude, and I try to conserve my snark for better use on internet forums. It became more awkward when she knowingly shook her head at my answer and went off on some bizarre tangent about denervated hearts in transplant patients. And then I had to take the time, later, to re-explain the whole thing to my med student and deprogram the faulty info she'd helpfully provided.

    But I'm quite happy to be pimped on internet forums, because I'm perfectly free to answer or not answer, and there are 100 bystanders lurking to do reality checks.

    I like threads like this. I've never seen a carcinoid tumor, and posts like these lend a touch of reality to something that up to now was just another paragraph in another book. Thanks trinityalumnus.
     
  29. fakin' the funk

    fakin' the funk ASA Member
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    I'm sure I'll look very lean and mean in the OR when I say "catecholamines may evoke serotonin release" and "catecholamines may cause the release of kallikrein." Then, when asked HOW, I can say "a nurse and Noyac said so."

    This is mechanism-less handwaving that would make me look like a ******.
     
  30. Planktonmd

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    OK, Here is the deal:

    In Carcinoid syndrome MAO Enzyme is busy metabolizing Serotonin, which makes it less available to metabolize other amines.
    So any medication that requires MAO for it's metabolism might theoretically cause exaggerated effect.
    Think of it like you think of a patient on MAOI, not as bad though.
     
  31. Planktonmd

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    I could never figure it out: Why on earth some people like to infuse long acting drugs????
    If you want the drug to last longer use longer acting drugs, how about Pancuronium and Morphine or Hydromorphone intermittent dosing?
    The only thing you will get from infusing Fentanyl and Cisatracurium is unpredictable half life and accumulation.
     
  32. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    Quote: I could never figure it out: Why on earth some people like to infuse long acting drugs????

    If you want the drug to last longer use longer acting drugs, how about Pancuronium and Morphine or Hydromorphone intermittent dosing?
    The only thing you will get from infusing Fentanyl and Cisatracurium is unpredictable half life and accumulation.

    Reply:

    1. Don't want to use MSO4 on carcinoid.

    2. Sometimes these cases end early and abruptly when the surgeon realizes he can't accomplish his surgical goals due to surprises of the anatomy or pathology, and at that point extubation might be a realistic possibility. Therefore, we don't use longer-acting drugs.

    3. Hospital doesn't have remifentanil

    4. If the case goes to the expected conclusion, it will be quite a while before the pt's ready for extubation anyway - and we sometimes have to pack open, cover with sterile ioban, and return to the OR the following morning.

    5. I've never been burned by cis accumulation, I would imagine due to the Hoffman elimination. And the fentanyl is only 50-75 mics/hr on pump with intermittent IV push as needed.
     
  33. 2ndyear

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    I'll set up an infusion for big cases that don't get extubated as well. Fentanyl 50-75 mcg/hr works pretty well for livers. None have epidurals, and it's one less thing for me to worry about when I've got my hands full doing other things. Makes for a more stable anesthetic. I like pancuronium, but we don't have Nimbex.
     
  34. Planktonmd

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    1- That stuff about not using morphine in carcinoid is an urban legend.
    2- There is two ideas in your response that oppose eachother, one of them is about being able to extubate on a short notice and the other is about not extubating because it doesn't matter, so which one you are trying to accomplish?
    3- It takes 5 times the half life of a medication to achieve a new steady state after each rate change, don't you think this is a little confusing if the half life is, lets say, 45 min?
    Again I have to say that it makes no pharmacological sense to infuse long acting drugs, but that doesn't mean people don't do it everyday.
     
  35. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    If the case goes to anticipated completion (many hours later) then it will be quite a while before the patient is extubatable --- so a little potential accumulation of intermediate-acting drugs is essentially a wash. Additionally, I titrate the nimbex to TOF, and the fentanyl is also adjusted based on a variety of indicators.

    Don't want to use longer acting (pavulon) if one hour into the case the surgeon suddenly announces "we're done" due to an intraabdominal surprise. This does happen occasionally. If we're using intermediate-acting, we have a much greater chance of extubating right then and there (which would be a goal in this particular circumstance).
     
  36. Planktonmd

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    OK, Whatever floats your boat :)
     
  37. Noyac

    Noyac ASA Member
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    Hey, if the nurse is teaching you something that you don't know then what does it matter who is teaching you, as long as what they are teaching is correct? I have been at this for a few years now and I am Boarded and very knowledgeable. But I would never pretend that I couldn't still learn something even if it is coming from a nurse.
     
  38. Noyac

    Noyac ASA Member
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    I agree Trinity.

    As far as Pancuronium, I never use it unless I know the pt will be intubated post op. It has been well documented that even full reversal of panc can still show residual relaxation post op. I see no need for it otherwise.
    I also agree with the fentanyl infusion. I use it in longer cases as well. Well, I use sufenta but its practically the same. It makes for a smooth case and smooth wakeup.
    And for Remi, we have it and I don't use it. I'm not that big of a fan. I like sufenta. I'm not saying that remi isn't as good (that **** is magical) just that I like the sufenta.
     
  39. Noyac

    Noyac ASA Member
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    And I guess you can provide proof.
     
  40. 2ndyear

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    Sufent is great because 5 cc will last all day, again leaving me more time to do other stuff than worry about the narcotic or even changing the infusion syringe.
     
  41. Planktonmd

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    The whole idea of avoiding Morphine is based on the histamine release assumption which can be minimized by giving small increments of the narcotic.
    I have used it in the few cases of Carcinoid I have seen without a problem, and I have used it in many other situations where histamine release could be a concern and as long as you don't give big doses rapidly you are ok.
    Now about providing proof, can you provide a study that shows that morphine can cause bad things in carcinoid surgery?

    Also one more thing I wish to highlight: I am not attacking anybody or disputing Trinity's theories because he is a CRNA, I am just giving my point of view.
     
  42. jeesapeesa

    jeesapeesa anesthesiologist southern california
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    dude you're an ass. haha, you can probably learn a few things from this dude.
     
  43. dhb

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  44. MTGas2B

    MTGas2B Cloudy and 50
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    Cis infusions are great. We use them routinely in our liver transplants. Admittedly we don't extubate them on the table, but they start trying to breath on their own on the way to the ICU. The kinetics are very predictable, probably more predictable than any other non-depolarizing agent.

    Fentanyl infusion are actually really nice if you use them properly. I had a streak of big spine cases at the VA where I used fentanyl. We routinely do our spines with TIVA for SSEP and MEP monitoring. The VA is cheap and the only synthetic opioid in the OR is fentanyl (we have remi and su at the UW and Harborview), so not many choices. Titrate during the case and just shut it down about 45 minutes from finish. Extubate them nice and comfortable, and it lasts when I roll into the unit, unlikely remi infusions which are great, but I've had PACU nurses complain that some of my colleagues forget to give patients anything else after the remi infusion comes off.
     
  45. Noyac

    Noyac ASA Member
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    I see your point (give it slowly) but I have never seen any proof of it beyond speculation and others personal experience. So I am not saying you are wrong but when you ask me for proof all I can say is that this is the textbook way of doing it. If I remember right every text book I have read states to avoid histamine releasing meds. Is this proof? Well its more than you have provided. :D
     
  46. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Fair enough.
     

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