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

PURPOSE: To report the anesthetic management of a patient with carcinoid tumour metastatic to the liver who presented for orthotopic liver transplantation. Anesthetic implications of metastatic carcinoid tumour on liver transplantation and the use of octreotide are discussed. CLINICAL FEATURES: A 51-yr-old woman with intestinal carcinoid tumour metastatic 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 continuous administration of the somatostatin analogue octreotide via a hepatic artery infusate pump, the patient suffered from daily break through symptoms, which included flushing, palpitations, paroxysmal hypertension, and dyspnea. The patient presented to the operating room with sinus tachycardia and severe arterial hypertension. Octreotide and phentolamine were used to prevent further mediator release and to control the paroxysmal hypertension. Midazolam, fentanyl, thiopental, succinylcholine, vecuronium, and isoflurane were used to induce and maintain anesthesia safely. An intravenous octreotide infusion was initiated after induction and continued throughout the case. Infrequent and non-threatening peaks in arterial blood pressure were readily treated with small intravenous doses of vasoactive drugs and octreotide. No other manifestations of the carcinoid syndrome occurred. The patient had an uneventful recovery and was discharged on postoperative day #6. CONCLUSION: The patient safely underwent orthotopic liver transplantation for treatment of symptomatic carcinoid tumour metastatic to the liver. The anesthetic management followed recent recommendations favouring the use of octreotide to prevent patients from becoming symptomatic. Outlined dosing regimen for octreotide provided satisfactory hemodynamic stability.

The monoclonal antibody AG-1, a potent stimulator of human platelets, interacts with a low molecular weight GTP-binding protein.

AG-1 is a monoclonal antibody that binds to human platelets and causes aggregation and secretion. Previous work has established that these responses result from phospholipase C-mediated hydrolysis of phosphatidylinositol 4,5-bisphosphate (PIP2). To determine the mechanism by which this ligand induces signals for platelet activation, we performed a series of experiments examining the platelet binding site for AG-1. AG-1 immunoprecipitates from radioiodinated human platelet plasma membranes a protein of Mr 21,000. AG-1 immunoprecipitated proteins separated by SDS-PAGE, transferred to nitrocellulose, and incubated with [alpha 32P]GTP demonstrate binding of the radiolabeled GTP to the Mr 21,000 protein. A 100-fold molar excess of unlabeled GTP inhibits completely this binding of [alpha 32P]GTP. These results indicate that AG-1 interacts with a low Mr GTP-binding protein on the surface of platelets and suggests that either the protein recognized by AG-1 or a coprecipitating molecule of similar Mr is a low Mr GTP-binding protein that may function in platelet extracellular signal transduction.