Cancer Immunotherapies: What the Perioperative Physician Needs to Know

Purpose of Review

For patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents.

Recent Findings

The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immune-related adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth.

Summary

Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.

A Retrospective Analysis of Patients Undergoing Telemedicine Evaluation in the PreAnesthesia Testing Clinic at H. Lee Moffitt Cancer Center

Background

Telemedicine for preanesthesia evaluation can decrease access disparities by minimizing commuting, time off work, and lifestyle disruptions from frequent medical visits. We report our experience with the first 120 patients undergoing telemedicine preanesthesia evaluation at Moffitt Cancer Center.

Methods

This is a retrospective analysis of 120 patients seen via telemedicine for preanesthesia evaluation compared with an in-person cohort meeting telemedicine criteria had it been available. Telemedicine was conducted from our clinic to a patient’s remote location using video conferencing. Clinic criteria were revised to create a tier of eligible patients based on published guidelines and anesthesiologist consensus.

Results

Day-of-surgery cancellation rate was 1.67% in the telemedicine versus 0% in the in-person cohort. The two telemedicine group cancellations were unrelated to medical workup, and cancellation rate between the groups was not statistically significant (P = .49). Median round trip distance and time saved by the telemedicine group was 80 miles [range 4; 1180] and 121 minutes [range 16; 1034]. Using the federal mileage rate, the median cost savings was $46 [range $2.30; 678.50] per patient. Patients were similar in gender and race in both groups (P = .23 and .75, respectively), but the in-person cohort was older and had higher American Society of Anesthesiologists physical status classification (P = .0003).

Conclusions

Telemedicine preanesthesia evaluation results in time, distance, and financial savings without increased day-of-surgery cancellations. This is useful in cancer patients who travel significant distances to specialty centers and have a high frequency of health care visits. American Society of Anesthesiologists Physical Status classification and age differences between cohorts indicate possible patient or provider selection bias. Randomized controlled trials will aid in further exploring this technology.

Rupture of an epidural filter connector during bolus administration of local anesthetic: a case report

BACKGROUND

Epidural catheters are routinely placed for many surgical procedures and to treat various pain conditions. Known complications arising from epidural catheter equipment malfunction include epidural pump failure, epidural catheter shearing, epidural catheter connector failure, epidural filter connector cracking, and loss-of-resistance syringe malfunction. Practitioners need to be aware of these potentially dangerous complications and take measures to mitigate the chances of causing significant patient harm. We report on the complete breakage of an epidural filter connector during epidural bolus administration of local anesthetic by hand with a syringe.

CASE PRESENTATION

A B. Braun Perifix® epidural catheter was placed in a 73-year-old male scheduled for radical prostatectomy. During the operation, a continuous infusion of local anesthetic was administered through the epidural catheter in addition to general endotracheal anesthesia. At the conclusion of surgery and after extubation, the patient endorsed incisional pain. The epidural filter connector broke in half as a bolus of local anesthetic was administered by hand with a syringe. The local anesthetic sprayed widely throughout the room as the fragmented epidural filter connector became a projectile object that recoiled and struck the patient.

CONCLUSIONS

This incident placed the patient and surrounding healthcare providers at substantial risk for injury and infection from the fractured epidural filter connector becoming a projectile object and from the local anesthetic spray. The most plausible cause of this event was from a large amount of pressure being applied to the filter connector. This may have occurred by excessive force being applied by hand to the syringe, by the presence of a clogged filter, or by the catheter being kinked or blocked proximal to the filter. Being aware of this deleterious complication and potentially modifying existing epidural bolus techniques, such as using smaller syringes with less applied force and checking all epidural components vigilantly prior to and during bolus administration, can help anesthesia providers deliver the safest possible care to patients with epidural catheters.

Intraoperative Hypotension in a Patient with Antithrombin Deficiency, Bilateral Pulmonary Emboli, and Cefazolin Allergy

In medicine, the search for a clear answer can at times be elusive. However, this does not necessarily preclude the administration of intelligent and thoughtful therapeutic treatments. Here, we describe a complicated emergent event of severe hypotension and near-arrest that occurred in the operating room in a young, healthy woman undergoing outpatient thyroid surgery. We detail the situation as it presented in the operating room and the measures taken to rule out potential life-threatening diagnoses and develop a thoughtful treatment plan. We further describe the evidence for and against the two remaining diagnostic possibilities: anaphylaxis versus acute pulmonary embolism.

Utility of Minimally Invasive Cardiovascular Monitoring in the High-Risk Patient Undergoing Radical Cystoprostatectomy: A Case Report

Non-cardiac surgery in a high-risk patient with severe mitral stenosis (MS) and severe pulmonary hypertension (PH) presents a significant anesthetic challenge. Guidelines recommend using advanced hemodynamic monitors for specific cardiovascular goals. The gold standard for intraoperative monitoring in these cases is the pulmonary artery catheter (PAC) and transesophageal echocardiography (TEE). This case discusses the successful management of a severe MS patient undergoing cystoprostatectomy using a minimally invasive cardiovascular monitor (MICM) incorporating several hemodynamic parameters. 

A Patient with an Intradural Tumor: An Unexpected Finding

Chronic back pain patients may require escalating doses of systemic opioids. In refractory cases, implantation of an intrathecal drug delivery system (IDDS) may provide effective relief of pain and improve overall function. This system infuses opioid directly into the cerebrospinal fluid via a catheter. While efficacious, it can be associated with complications, one of the most severe being the formation of a catheter-tip granuloma that can lead to permanent neurological deficits. We present a case of a 38-year-old male with an IDDS for pain related to retroperitoneal fibrosis, who began developing worsening back pain along with new-onset lower extremity weakness. A catheter-tip granuloma was suspected, and the patient was advised to obtain emergent spine imaging. He was non-compliant until the point of becoming wheelchair bound, whereupon imaging was finally obtained. Magnetic resonance imaging revealed an intradural mass causing spinal cord compression. After emergent surgical resection, pathology revealed a malignant tumor. Any patient with IDDS and escalating pain levels or new neurological deficits needs urgent neuroimaging to rule out catheter-tip granuloma. However, as this case demonstrates, the differential diagnosis should remain broad and always include neoplasm or abscess. 

Transesophageal Echocardiography During Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Novel Approach

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive, lengthy procedure for patients with peritoneal metastases. It is associated with fairly high morbidity and mortality as compared with other non-vascular intra-abdominal surgeries. Fluid and hemodynamic management is challenging and not well established, particularly in patients with a low ejection fraction (EF). This case details the successful intraoperative anesthetic management of a patient with an ejection fraction of 20% undergoing CRS/HIPEC using the addition of intraoperative transesophageal echocardiography (TEE) as an adjunct to central venous pressure (CVP), urine output (UOP), and calculated stroke volume variation (SVV) for goal-directed resuscitation and blood pressure support.