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Operative non-cardiogenic pulmonary oedema and pancreatic carcinoid tumour.

We report a case of intraoperative non-cardiogenic pulmonary oedema, most likely caused by release of vasoactive substances from a carcinoid tumour. A 28-year-old woman, ASA PS 1, weighing 49 kg was recently referred to our institution for exploration of a pancreatic tumour. No evidence of metastatic disease was detected. Histological examination of the endoscopic duodenal biopsy diagnosed adenocarcinoma. Preoperative physical examination was normal. Laboratory tests showed elevated serum bilirubin (total/conjugate bilirubin 52/39 [micro]mol.[l.sup.-1]). The patient received oral midazolam premedication (0.075 mg.k[g.sup.-1]) one hour before surgery, then 500 ml 0.9% saline as intravenous fluid loading over 20 minutes. Anaesthesia was induced with thiopentone 6 mg.k[g.sup.-1], fentanyl 3 [micro]g.k[g.sup.-1]. Atracurium 0.5 mg.k[g.sup.-1] was used for muscle relaxation. After tracheal intubation, anaesthesia was maintained with isoflurane (0.8-1 MAC), 50% nitrous oxide in oxygen and supplementary doses of fentanyl 1 [micro]g.k[g.sup.-1] per 30 min. After induction, a central venous catheter was inserted.

The patient's intraoperative course was initially uneventful. However, immediately after tumour mobilisation the patient developed facial flushing and progressive hypoxemia and tachycardia without significant hypotension. Her central venous pressure was 9 cm H[2.sub.O]. Arterial blood gases confirmed severe hypoxaemia (P[.sub.a]O[.sub.2]=40 mm Hg). Chest radiography showed bilateral pulmonary apex oedema (Figure 1). Surgery was then suspended and the [F.sub.I][O.sub.2] was increased to 1.0 with 8 cm[H.sub.2]0 PEEP She was also given frusemide 80 mg IV and transferred to the intensive care unit. Postoperative electrocardiogram and echocardiogram were normal. Tracheal extubation was possible three hours later. Twenty-four hours later, chest radiography showed total resolution of the infiltrate (Figure 2). Perfusion lung scintography did not support a diagnosis of pulmonary embolism. Unfortunately, 10 days after her surgery, the patient developed a massive digestive tract haemorrhage and died. The final histopathological examination confirmed a carcinoid tumour. Immunohistochemical labeling studies demonstrated tumour positivity for chromograffin. It was also noted that her 24-hour urinary excretion of 5-hydroxyindole acetic acid was elevated at 95 mg (normal <6 mg/24h).

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Carcinoid tumours secrete a wide variety of physiologically active substances that can induce a variety of clinical-pathological syndromes'. However, to our knowledge, acute non-cardiogenic pulmonary oedema has never been reported in patients with carcinoid tumours in the gastrointestinal tracte. We hypothesise that her intraoperative deterioration resulted from acute elevation of kallikrein released during surgical manipulation of the tumour. This postulate is supported by kallikrein action on kininogen precursors to generate bradykinin, which enhance microvascular permeability(3). In our patient, pulmonary oedema resolved rapidly with standard therapy.

The use of octreotide intraoperatively in patients with carcinoid tumours undergoing intra-abdominal surgery is associated with a decreased frequency of carcinoid crises(4). Octreotide was not used in our case because the diagnosis was not made until postoperatively. However, this case suggests that a carcinoid syndrome should be suspected in cases of unexplained intra-operative non-cardiogenic pulmonary oedema, and that the use of octreotide should be considered.

References

(1.) Calhoun K, Toth-Fejel S, Cheek J, Pommier R Serum peptide profiles in patients with carcinoid tumors. Am J Surg 2003; 186:28-31.

(2.) Holdcroft A. Hormones and the gut. Br J Anaesth 2000; 85:5668.

(3.) Campbell DJ. Towards understanding the kallikrein-kinin system: insights from measurement of kinin peptides. Braz J Med Biol Res 2000; 33:665-677.

(4.) Kinney MA, Warner ME, Nagorney DM, Rubin J, Schroeder DR, Maxson PM et al. Perianaesthetic risks and outcomes of abdominal surgery for metastatic carcinoid tumours. Br J Anaesth 2001; 87:447-452.

M. MTAALLAH

M. BOUSSOFARA

H. BOUSSEN

K. RAHAL

Tunis, Tunisia
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Article Details
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Title Annotation:Correspondence
Author:Mtaallah, M.; Boussofara, M.; Boussen, H.; Rahal, K.
Publication:Anaesthesia and Intensive Care
Article Type:Case study
Geographic Code:1USA
Date:Feb 1, 2007
Words:630
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