Perioperative management of the patient with cancer

Clinical implications of chemotherapeutic agent organ toxicity on perioperative care

Cancer is the second most common cause of death in the United States and is a challenging disease to treat. The treatment options for various cancers include but are not limited to surgery, radiation, and chemotherapy. The mechanism behind chemotherapy is intended to promote cellular damage to cells that are proliferating uncontrollably. Unfortunately for the recipients, most chemotherapeutic agents cannot differentiate between malignant cells and healthy cells and tissues. Thus, chemotherapy-induced toxicities are often observed in once-healthy organs. These effects can be acute and self-limiting or chronic, appearing long after chemotherapy is completed. Cancer survivors can then present for non-cancer related surgeries later in life, due to this toxicity. Furthermore, the administration of chemotherapeutic agents can profoundly impact the anesthetic management of patients who are undergoing surgery. This review discusses how chemotherapy-induced organ toxicity can occur in multiple organ systems and what drugs should be avoided if prior toxicity exists in these organ systems.

Translational advances in pain and anesthesia for cancer patients

Effective cancer pain management requires multidisciplinary approaches for multimodal analgesia. Although opioids have been the cornerstone, developments such as regional anesthesia and interventional pain techniques, complementary and alternative medicine, and new pharmaceuticals also have shown promise to relieve cancer pain. This overview of relevant clinical efforts and the modern day state of the science will afford a better understanding of pain mechanisms and multimodal approaches beneficial in optimizing analgesia for cancer patients.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

A pilot study evaluating predictors of postoperative outcomes after major abdominal surgery: Physiological capacity compared with the ASA physical status classification system

Background

This pilot study compared the risk predictive value of preoperative physiological capacity (PC: defined by gas exchange measured during cardiopulmonary exercise testing) with the ASA physical status classification in the same patients (n=32) undergoing major abdominal cancer surgery.

Methods

Uni- and multivariate logistic regression models were fitted to measurements of PC and ASA rank data determining their predictive value for postoperative morbidity. Receiver operating characteristic (ROC) curves were used to discriminate between the predictive abilities, exploring trade-offs between sensitivity and specificity.

Results

Individual statistically significant predictors of postoperative morbidity included the ASA rank [P=0.038, area under the curve (AUC)=0.688, sensitivity=0.630, specificity=0.750] and three newly identified measures of PC: PAT (% predicted anaerobic threshold achieved, <75% vs ≥75%), ΔHR1 (heart rate response from rest to the anaerobic threshold), and HR3 (heart rate at the anaerobic threshold). A two-variable model of PC measurements (ΔHR1+PAT) was also shown to be statistically significant in the prediction of postoperative morbidity (P=0.023, AUC=0.826, sensitivity=0.813, specificity=0.688).

Conclusions

Three newly identified PC measures and the ASA rank were significantly associated with postoperative morbidity; none showed a statistically greater association compared with the others. PC appeared to improve predictive sensitivity. The potential for new unidentified measures of PC to predict postoperative outcomes remains unexplored.

Report on a patient with pre-existing venous thrombosis and incidental malignancy undergoing urgent laparotomy: preoperative concerns

The management of a patient with pre-existing deep venous thrombosis (DVT) who was subsequently found to have a malignancy planned for urgent laparotomy is reported.A 30-year-old woman presented to the emergency room and was diagnosed to have a DVT. During work-up, she was found to have a malignanacy and was scheduled for urgent laparotomy. The patient was put on enoxaprin (injection) and warfarin (tablets). The patient was started on heparin (injection) 1000 IU/h at 72 h prior to operation, stopped 6 h prior to surgery. Anaesthesia and surgery were uneventful.A number of issues related to pre-existing DVTs prior to gynaecological surgery require further clarification; the optimal duration of pharmacological treatment, and the optimal duration/modality of prophylaxis to prevent thromboembolism in high-risk patients with cancer.Patients presenting for DVT must be evaluated for its causative factor(s), and malignancy in particular, based on clinical findings and investigations. Before planning surgical procedures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism and pulmonary embolism in particular.

Chemotherapy and anaesthetic drugs: too little is known

A growing number of patients undergo surgical procedures with general anaesthesia soon after receiving chemotherapy; occasionally such treatment can be given during surgery. Therefore, it is worthwhile and prudent to consider the pharmacological interactions between anticancer and anaesthetic drugs. We review published data on the pharmacological interactions between antineoplastic and anaesthetic drugs, despite the fact that this specific topic is poorly represented in published work. This low coverage seems to be due more to a lack of knowledge and understanding rather than an absence of interactions between the two drug types. Since the number of individuals receiving chemotherapy in the perioperative period is rising, patients who might have potentially dangerous and unwanted effects are also due to increase in number. Thus, we should be vigilant in the careful surveillance of these interactions as well as broaden our knowledge of in-vivo and in-vitro findings and investigations. Classic cytostatic compounds and modern drugs should be extensively studied, and new anticancer therapies closely interacting with immunological responses need to be better understood, since their clinical effectiveness might be modified by anaesthetics that are currently used. More frequently, tumours are being managed in a multimodal integrated approach with medical, surgical, and radiotherapeutic aspects.