Orthotopic liver transplantation for carcinoid tumour metastatic to the liver: anesthetic management

Purpose: To report the anesthetic management of a patient with carcinoid tu mour metastatic to the liver who presented for orthotopic liver transplanta tion. Anesthetic implications of metastatic carcinoid tumour on liver trans plantation and the use of octreotide are discussed. Clinical features: A 51-yr-old woman with intestinal carcinoid tumour metas tatic to the liver presented for orthotopic liver transplantation, a recent treatment option for patients with extensive hepatic carcinoid metastases and disabling symptoms unresponsive to conventional therapy. Despite contin uous administration of the somatostatin analogue octreotide via a hepatic a rtery infusate pump, the patient suffered from daily break through symptoms , which included flushing, palpitations, paroxysmal hypertension, and dyspn ea. The patient presented to the operating room with sinus tachycardia and severe arterial hypertension. Octreotide and phentolamine were used to prev ent further mediator release and to control the paroxysmal hypertension. Mi dazolam, fentanyl, thiopental, succinylcholine, vecuronium, and isoflurane were used to induce and maintain anesthesia safely, An intravenous octreoti de infusion was initiated after induction and continued throughout the case . Infrequent and non-threatening peaks in arterial blood pressure were read ily treated with small intravenous doses of vasoactive drugs and octreotide . No other manifestations of the carcinoid syndrome occurred. The patient h ad an uneventful recovery and was discharged on postoperative day #6, Conclusion: The patient safely underwent orthotopic liver transplantation f or treatment of symptomatic carcinoid tumour metastatic to the liver. The a nesthetic management followed recent recommendations favouring the use of o ctreotide to prevent patients from becoming symptomatic, Outlined dosing re gimen for octreotide provided satisfactory hemodynamic stability.