Carcinoid crisis

What is carcinoid crisis?

Carcinoid crisis is a life-threatening episode of hypotension, flushing, and bronchospasm that is triggered most often by tumor manipulation or anesthesia and less commonly by chemotherapy, hepatic artery embolization, or radionuclide therapy. It can also be provoked by the administration of adrenergic agents, such as epinephrine and sympathomimetic amines, or monoamine oxidase inhibitors (MAOIs) in patients with underlying carcinoid tumors.

How can carcinoid crisis be prevented?

When patients with carcinoid syndrome undergo surgery or hepatic artery embolization for their tumor or metastases, they should be pretreated with octreotide (300–500 mcg) subcutaneously or intravenously 30 to 60 minutes before the procedure. Repeat dosing during the surgery or procedure may be needed to prevent hypotension. Despite these measures, carcinoid crisis can still occur. Anesthesiologists should be specifically notified that the patient has carcinoid syndrome. Epinephrine, sympathomimetic amines, and MAOIs should be avoided in patients with carcinoid syndrome.

Who should receive prophylaxis to prevent carcinoid crisis?

All patients with symptomatic carcinoid syndrome, even if symptoms are well controlled with the above measures, should receive octreotide prophylaxis for surgery or procedures that can precipitate carcinoid crisis. Patients who have metastatic NETs, even in the absence of carcinoid syndrome symptoms, should have measurement of 24-hour urinary 5-HIAA excretion; octreotide prophylaxis, as described above, should be used in those with elevated urinary 5-HIIA levels.

How is carcinoid crisis treated?

Effective treatment for carcinoid crisis consists of IV administration of octreotide and glucocorticoids. If this does not abort the episode, additional options include methotrimeprazine (an antiserotonin agent), methoxamine (a direct vasoconstrictor), phentolamine (an alpha-adrenergic blocker), ondansetron (a serotonin receptor antagonist), and glucagon. It is critical to avoid the use of adrenergic and sympathomimetic agents in patients with suspected carcinoid crisis because these drugs can significantly worsen the condition. Effective medication dose regimens for this condition are listed in the below table.

Management of Carcinoid Crisis

MEDICATIONDOSE REGIMEN
Octreotide (Sandostatin)50 mcg IV over 1 min, then 50 mg IV over 15 min
Hydrocortisone (Solu-Cortef)100 mg IV over 15 min
Methotrimeprazine (Levoprome)2.5–5.0 mg slow IV push
Methoxamine (Vasoxyl)3–5 mg slow IV push, followed by an infusion
Phentolamine (Regitine)5 mg slow IV push
Ondansetron (Zofran)20 mg IV over 15 min
Glucagon0.5–1.5 mg slow IV push

IV, Intravenous.

Source

From Warner, R. R. P. (1997). Gut neuroendocrine tumors. In C.W. Bardin (Ed.), Current therapy in endocrinology and metabolism (6th ed., pp. 606–614). St. Louis, MO: Mosby

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