Page 1558 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 113: The Acute Abdomen and Intra-abdominal Sepsis 1077

include need for steroid administration after bilateral adrenalectomy and • Hirsch J, Guyatt G, Albers GW, et al. Anthithrombotic and
close observation for hypoglycemia in all patients. 114 thrombolytic therapy (eighth edition): AACP guidelines. Chest.
Carcinoid tumors are uncommon neoplasms with an incidence of 2008;133(6 suppl):110S-112S.
0.28 to 10 per 100,000 persons, although autopsy series have demon-
strated incidental carcinoid as high as 8%. 115,116 They are neuroendocrine • Hockstein MJ, Barie PS. General Principles of Post-operative
tumors derived from enterochromaffin or Kulchitsky cells that secrete a Intensive Care. Philadelphia, PA: Mosby Elsevier; 2008.
variety of vasoactive amines and peptides, most importantly serotonin, • Kinney MAO, Narr BJ, Warner MA. Perioperative management
histamine, and kinin peptides. 115,116 Carcinoid syndrome occurs only of pheochromocytoma. J Cardio Vasc Anesth. 2002;16(3):359-369.
when this release is into the systemic circulation as is the case in primary • Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after
bronchial, genitourinary, thyroid, breast, pancreas, thymus, primary or cardiac surgery. Ann Intern Med. 2001;135:1061-1066.
metastatic cardiac, or primary or metastatic liver lesions. While most • Mancuso K, Kaye AD, Boudreaux JP, et al. Carcinoid syndrome
(75%) carcinoid tumors originate from the GI tract, tumors that secrete and perioperative anesthetic considerations. J Clin Anesth. 2011;
into the portal system do not result in a carcinoid syndrome because of 23:329-341.
liver metabolization of the active substances.
The carcinoid syndrome is a syndrome that is manifest as lability, • Mazzeffi M, Zivot J, Buchman T, Halkos M. In-hospital mortality
cutaneous flushing, bronchoconstriction, diarrhea, and carcinoid heart after cardiac surgery: patient characteristics, timing, and associa-
disease. Cardiac involvement is primarily right sided because of the tion with postoperative length of intensive care unit and hospital
ability of the pulmonary system to clear the tumor mediators. Carcinoid stay. Ann Thorac Surg. 2014;97(4):1220-1225.
plaques development on valve leaflets resulting in tricuspid regurgitation, • McCarthy EJ. Malignant hyperthermia: pathphysiology, clinical
pulmonary insufficiency or stenosis, arrhythmias, right heart failure, presentation, and treatment. AACN Clin Issues. 2004;15(15):231-237.
and less likely, left-sided lesions, myocardial metastases, and pericardial • Mebazza A, Karpati P, Renaud E, Algotsson L. Acute right ven-
effusion. Left-sided lesions are more common in primary bronchial tricular failure-frm pathophysiology to new treatments. Intensive
tumors, which may also be associated with pulmonary hypertension and Care Med. 2004;30:185-196.
severe bronchospasm. A life-threatening form of carcinoid syndrome is • Memon M, Memon M, Donohue JH. Abdominal drains: a brief
termed carcinoid crisis and occurs after tumor manipulation, chemical historical review. Isr Med J. 2001;94:164-166.
stimulation, anesthesia induction, or chemotherapy-induced tumor necro-
sis. Carcinoid crisis is characterized by large blood pressure variability, • Mueller AR, Platz K-P, Kremer B. Early postoperative com-
arrhythmias, bronchoconstriction, and altered mental status; flushing is a plications following liver transplantation. Best Pract Res Clin
warning sign that impending crisis may result if not treated. Preoperative Gastroenterol. 2004;18(5):881-900.
symptom severity is not associated with perioperative complications, so • Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment
preparation for carcinoid crisis, especially bronchospasm, cardiovascular outcomes of early enteral vs early parenteral nutrition in hospital-
instability, and hyperglycemia should be performed in all patients. 116 ized patients. Crit Care Med. 2005;33:213-220.
Emergence from anesthesia may be associated with a variety of clinical • Sanders AB. Therapeutic hypothermia after cardiac arrest. Curr
symptoms largely dependent on the bioactive substance that is released. Opin Crit Care. 2006;12:213-217.
Bronchospasm, vomiting, hyperglycemia, and prolonged drowsiness • Spodick D. Acute cardiac tamponade. N Engl J Med. 2003;349:
may all occur during emergence. Postoperatively, vasoactive substances 684-690.
can continue to be released, especially in patients with high preoperative
serotonin levels. Octreotide, a somatostatin analog, is the primary agent • Varghese R, Anyanwu AC, Itagaki S, Milla F, Castillo J, Adams DH.
used for chronic and acute symptom control. It should be administered Management of systolic anterior motion after mitral valve repair:
intravenously in the intraoperative period and slowly weaned to the an algorithm. J Thorac Cardiovasc Surg. 2012;143:S2-S7.
depot form over the first week postoperatively. Postoperative hypoten-
sion from tumor mediators responds quickly to increases in octreotide
dosing. Bronchospasm can be severe and resistant to typical treatments. REFERENCES
β-Agonists can actually result in further tumor mediator release wors-
ening the problem. Octreotide works well for bronchospasm, as do Complete references available online at www.mhprofessional.com/hall
nebulized anti-cholinergics such as ipratropium. Anxiolytics can help
prevent stress-triggered release of serotonin and H and H blockers
2
1
can be used in histamine-secreting tumors. Postoperative monitoring
for hyperglycemia should be performed with insulin infusion initiated The Acute Abdomen
as necessary. Lastly, fluids and electrolytes should be monitored closely CHAPTER
secondary to large intraoperative fluid shifts. 116 and Intra-abdominal Sepsis
113
Elisa F. Greco
KEY REFERENCES John M. A. Bohnen
• Cerfolio RJ. Recent advances in the treatment of air leaks. Curr
Opin Pulm Med. 2005;11(4):319-323. KEY POINTS
• Fedorow CA, Moon MC, Mutch WAC, Grocott HP. Lumbar • The acute abdomen presents in unusual ways in the intensive care
cerebrospinal fluid drainage for thoracoabdominal aortic surgery: unit (ICU).
rationale and practical considerations for management. Anesth • Successful management depends on prompt diagnosis and
Analg. 2010;111(1):46-58. management; the intensivist, surgeon, gastroenterologist, and
• Goldberg JB, Goodney PP, Kumbhani SR, Rother RM, Powell RJ, radiologist must collaborate effectively.
Likosky DS. Brain injury after carotid revascularization: outcomes,
mechanisms, and opportunities for improvement. Ann Vasc Surg. • Computed tomography (CT) and ultrasonography should be used
liberally to evaluate abdominal conditions.
2011;25(2):270-286.

section10.indd 1077 1/20/2015 9:19:47 AM