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Anesthetic Management of the Cancer Patient
Transcript of Anesthetic Management of the Cancer Patient
of the Cancer Patient
Discuss surgical and anesthetic impacts on immunosuppression, which can lead to cancer recurrence
Review key elements of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)
Identify implications for practice
Surgical and Anesthesia-mediated Immunosuppression
Cancer Growth & Recurrence: Implications for Anesthesia
Always strive to maintain:
Surgical Stress Response
Cell-mediated immunosuppression d/t inhibition of natural killer (NK) cells
Directly related to degree of surgical trauma and tissue damage
Lasts up to 1 week after surgery
by Non-pharmacologic means
Neuroendocrine system & HPA Axis
immune modulation (TRIM)
Decreased NK cell cytotoxicity
Altered NK cell-mediated release of cytokines
Volatile agents + Opioids
Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy
Transfused patients experience immunosuppression:
Increased nosocomial and postop infections
Increased cancer recurrence
Improved survival rates s/p transplant
Decrease NK cell function
Altered ratio of helper:suppressor T lymphocytes
Decreased lymphocyte blastogenesis
Down-regulation of immune system
What is HIPEC?
Massive fluid shifts
Insensible loss + blood loss + albumin loss
Increased: INR, PTT
Decreased: ATIII, fibrinogen, platelet count
Transfusion (PRBC or FFP) often required
Intraop: ~ 50% of cases
Postop: ~ 33% of cases
5% glucose mixture: hyperglycemia/hyponatremia
laryngeal and pharyngeal dysesthesias
Nephrotoxicity and pulmotoxicity
Arrhythmias and cardiomyopathy
Peripheral neuropathy and renal failure
Pulse-less amiodarone-refractory VTach
d/t loss of magnesium and QT prolongation
Neuroendocrine system & HPA Axis modification
Restrictive transfusion policy:
Hgb 7-8.5 G/dL
Must be case-by-case
Use cell saver blood
Consider pre-op recombinant EPO
Reduce unnecessary blood draws
NSAIDS for the Cancer Patient
Reduce COX-2 inflammatory pathway and reduce opioid consumption
Retrospective study of mastectomies from 2003-2008 (n=327)
Ketorolac group = 5-fold reduction in relapse (Forget, et al., 2010)
Beta Blocker Therapy
Blocks noxious input to CNS and reduces the stress response
Helps avoid potential negative results of volatile agents and reduce opioid requirement
 Reduced length of stay (16.08, 21.58 days) and prolonged length of survival (95.9, 70.4 months)
 Risk of recurrence 57% lower in epidural group
 Increased length of cancer-free survival (24 months: 94% vs 82%; 36 months: 94% vs 77%)
Several observational studies show that patients taking beta blockers have reduced cancer development
Early research shows that non-selective beta antagonists (propranolol) diminish the stress response and abolish the pro-metastatic effect of norepinephrine
Propanolol + COX Inhibitor = synergistic block of cell-mediated immunosuppression
Implication for Practice:
Lines & Labs
Always: large bore IV access
Often: arterial line
Sometimes: central line + CVP monitoring
Metabolic acidosis/respiratory derangements
Consider DIC screen
Consider ACT (bedside monitoring)
Implications for Practice:
Aggressive fluid administration
Close monitoring of UOP. If UOP drops:
Loop diuretic (Lasix)
Osmotic diuretic (Mannitol)
Cisplatin: Consider Na Thiosulfate infusion
Check/replace electrolytes (K+, Ca+, Mag)
Implications for Practice:
Fluids & Blood
Crystalloid vs colloid
Hespan often avoided d/t coagulopathies
Cell saver (limit use of banked blood)
Coagulopathic patient: First-line is FFP
Know institutional transfusion policy
Management of HIPEC Phase
Increased abdominal pressure:
Decreased venous return
Increased splanchnic resistance
Displacement of diaphragm
Increased mean airway pressures
Goal: maintain minute ventilation without high mean airway pressures
Cytoreduction [COLD] phase:
Bair Hugger + fluid warmer
Consider letting temp drift as low as 35 C before HIPEC initiated
HIPEC [HOT] Phase:
Cooling blanket, chilled IVF, forced air warmer on ambient setting
Consider permissive hyperthermia (39-40 C)
Increased O2 demand, HR, ETCO2
Intraop: fentanyl + dilaudid
Postop: sometimes morphine PCA
Thoracic epidural analgesia
Reduced ICU days, ventilator time, & consumption of opioids. N=20. (Mahran & Thabet, 2012)
Assess for pre-op coagulopathy
Monitor for epidural hematoma
Patients who undergo surgery with GA have greatly increased rates of unrelated cancers c/t the predicted rates for their population
N = 13, 488. Augmentation mammoplasty. 21% increased risk of any cancer within 12 years; doubled risk of leukemia, stomach CA, & brain CA (Brinton, et al., 2001).
Occult cancers are common, with healthy people concealing cancers that never become clinically active [autopsy studies]
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Massive fluid losses & shifts
Risk of acute renal failure
Multimodal pain management
Our impact extends beyond the OR
Actively seek out emerging evidence
Morphine, fentanyl, remifentanil, methadone, codeine
Buprenorphone, hydromorphone, oxycodone, tramadol
Current, multi-center NIH study:
Stage I-III patients undergoing mastectomy or isolated lumpectomy + axillary dissection
Group I - thoracic epidural or paravertebral anesthesia/analgesia
Group II - GA (Sevo) + morphine
Assessing rate of recurrence/metastasis over 10 years (2007-2017)
(Kurosawa, 2012; Gottschalk, et al., 2010; Arain & Buggy, 2007)
(Altman, et al., 2010;
Brasky, et al., 2009;
Brinton, et al., 2001;
Goldstein & Macitelli, 2011;
McLaughlin, et al., 1998;
Nauman, et al., 2008)
(Bovill, 2010; Goldstein & Macitelli, 2011; Goldfarb & Ben-Eliyaho, 2006; Shakhar & Ben-Eliyaho, 2003)
(Outcomes Research Consortium, 2012)
Treatment for surface peritoneal malignancies
Extends life expectancy by 16-24 months c/t traditional systemic therapy
3-5 L of heated chemotherapy (42-43 degrees C) instilled into peritoneum
Chemo circulates for 30-120 minutes
Total OR time: 4-11.5 hours (average 5-6 hours)
(Raspe, et al., 2012; Schmidt, et al., 2008)
(Bell, et al., 2012; Raspe, et al., 2012; Schmidt, et al., 2008)
(Bell, et al., 2012; Mahran & Thabet, 2012; Raspe, et al., 2012; Schmidt, et al., 2008; Owusu-Agyemang, 2012)
(Dougenis, et al., 2001; Rahgavan & Malik, 2005; Webber, Jabour & Martin, 2008)
(Bovill, 2010; Kurosawa, 2012)
(Bovill, 2012; Kurosawa, 2012; Sacerdote, 2006)
Surgery + GA can trigger microscopic cancers which typically remain dormant to convert to active cancer or recurrence
Increased susceptibility to cancer growth
(Algazi, et al., 2004; Benish, et al., 2008; Biki, et al., 2006; Dougenis, et al., 2001; Exadaktylos, et al., 2006; Forget, et al., 2010; Gottschalk, et al., 2012; Palm, et al., 2006; Perron, et al., 2004; Rhagavan & Malik, 2005; Weber, Jabbour, & Martin, 2008;
Inflammation is the "fuel that feeds the flames"
Body's response to stress
Impaired cellular immune responses