Race, Ethnicity, and Sustained Opioid Use After Major Abdominal Surgery for Cancer

Purpose

Sustained opioid use is a well-known complication after surgery. Our objective was to determine whether there is any association between a patient's race or ethnicity and the sustained use of opioids in the year following surgery. Opioid use over the initial 3, 6, and 12 postoperative months was categorized as "sustained early", persistent, and chronic, respectively.

Patients and Methods

Single-institution retrospective study of adults (≥18 years) who had undergone open abdominal surgery for cancer. Multivariable logistic regression was used to evaluate the association between race/ethnicity and opioid use.

Results

Of the 3523 patients included in the study, 2543 (72.2%) were non-Hispanic (NH) White, 476 (13.5%) were Hispanic or Latino, 262 (7.4%) were NH-Black, 186 (5.3%) were Asian, and 56 (1.6%) belonged to other racial or ethnic groups. The overall rates of sustained early, persistent, and chronic opioid use were 15.9%, 7.1%, and 2.6%, respectively. In the multivariable analysis, patient race/ethnicity was associated with sustained early postoperative opioid use (p-value=0.037), with Hispanics/Latinos having significantly higher odds than NH-Whites (OR = 1.382 [95% CI: 1.057-1.808]; p = 0.018). However, neither persistent nor chronic opioid use was associated with race/ethnicity (p = 0.697 and p = 0.443, respectively).

Conclusion

In this retrospective study of adults who had undergone open abdominal surgery, patient race/ethnicity was not consistently associated with the development of sustained opioid use over the first 12 postoperative months.

The Impact of the Need for Language Assistance Services on the Use of Regional Anesthesia, Postoperative Pain Scores and Opioid Administration in Surgical Oncology Patients

Language barriers can negatively impact the quality of healthcare. In surgical patients, limited English proficiency (LEP) can lead to disparities in acute postoperative pain management. Interpreters are often used for communication with LEP patients to help alleviate these disparities. We aimed to investigate the impact of the need for language assistance services (LAS) in acute postoperative pain management in patients undergoing oncologic surgery. We retrospectively collected data on adult patients undergoing open abdominal oncologic surgery between March 2016 and August 2021. The need for LAS, patient demographics, treatment and clinical outcomes were obtained from the patient's electronic medical record. The primary endpoint was pain intensity, while secondary endpoints included opioid use in PACU and regional anesthesia. Post-matching analysis (n = 590) demonstrated no significant difference in preoperative variables between patients needing LAS and those not needing LAS. The rate of regional use was slightly lower but not statistically significant in patients needing LAS. Patients needing LAS had significantly lower opioid consumption and reported lower pain intensity in PACU than subjects not requiring translation. In this study, LAS may have aided in the patient decision process regarding the acceptance of regional anesthesia. Although the need for LAS was associated with statistically significant lower pain intensity scores and a corresponding lesser opioid use than no LAS, the margin of differences, especially in pain intensity scores, may not be clinically significant. This may suggest that LAS allowed for better patient-provider communication and appropriate pain management.

Temperature management during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

In addition to attaining complete or near complete cytoreduction, the instillation of select heated chemotherapeutic agents into the abdominal cavity has offered a chance for cure or longer survival inpatients with peritoneal surface malignancies. While the heating of chemotherapeutic agents enhances cytotoxicity, the resulting systemic hyperthermia has been associated with an increased risk of severe hyperthermia and its associated complications. Factors that have been associated with an increased risk of severe hyperthermia include intraoperative blood transfusions and longer perfusion duration. However, the development of severe hyperthermia still remains largely unpredictable. Thus, at several institutions, cooling protocols are employed during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Cooling protocols for CRS-HIPEC are not standardized and may be associated with episodes of severe hyperthermia or alternatively hypothermia. In theory, excessive cooling could result in a decreased effectiveness of the intraperitoneal chemotherapeutic agents. This presumption has been supported by a recent study of 214 adults undergoing CRS-HIPEC, where failure to attain a temperature of 38° C at the end of chemo-perfusion was associated with worse survival. Although not statistically significant, failure to maintain a temperature of 38° C for at least 30 minutes was associated with worse survival. Although studies are limited in this regard, the importance of maintaining a steady state of temperature during the hyperthermic phase of intraperitoneal chemotherapy administration cannot be disregarded. The following article describes the processes and physiological mechanisms responsible for hyperthermia during CRS-HIPEC. The challenges associated with temperature management during CRS-HIPEC and methods to avoid severe hypothermia and hyperthermia are also described.

Race, ethnicity, and the use of regional anesthesia in cancer patients undergoing open abdominal surgery: A single-center retrospective cohort study

Background

Where applicable, regional anesthesia has been shown to be superior to opioid or non-opioid analgesic modalities alone. However, some studies have shown ethnic-based disparities in the use of regional anesthesia in patients undergoing surgical procedures. In this study of patients who had undergone major oncologic surgery, our main objective was to compare the use of regional anesthesia between patients of different ethnicities.

Methods

A retrospective review of adults who had undergone major open abdominal surgical procedures between 2016 and 2021 was performed. Logistic regression models were used to assess the association between baseline patient characteristics and the use of regional anesthesia.

Results

A total of 4,791 patients were included in the analysis. The median age was 60.5 years [interquartile range, 49, 69], the majority were female (65%), and of American Society of Anesthesiologists Physical Status Class (ASA) 3 (94.7%). Regional anesthesia was used in 2,652 patients (55.4%) and was not associated with race or ethnicity (p = 0.287). Compared to White patients, the odds of regional anesthesia use in other racial/ethnic groups were: Asian {odds ratio (OR) 0.851 [95% confidence interval (CI), 0.660–1.097]; p = 0.2125}, Black/African American [OR 0.807 (95% CI, 0.651–1.001); p = 0.0508], Hispanic/Latino [OR 0.957 (95% CI, 0.824–1.154); p = 0.7676], Other race [OR 0.957 (95% CI, 0.627–1.461); p = 0.8376]. In the multivariable analysis, age [OR 0.995 (95% CI, 0.991–1.000); p = 0.0309] and female gender [OR 1.231 (95% CI, 1.090–1.390); p = 0.0008] were associated with the use of regional anesthesia.

Conclusion

In this single-institution retrospective study of adults who had undergone major open abdominal surgery, the use of regional anesthesia was not associated with race or ethnicity. In the multivariable analysis, age and female gender were associated with the use of regional anesthesia.

Survey of Anesthesia, Sedation, and Non-sedation Practices for Children Undergoing Repetitive Cranial or Craniospinal Radiotherapy

Background

Children undergoing cranial or craniospinal radiotherapy may require over 30 treatments within a six-week period. Facilitating these many treatments with the patient under anesthesia presents a significant challenge, and the most preferred anesthetic methods remain unknown. The primary goal of this study was to determine the most preferred anesthetic methods and agents for children undergoing daily cranial or craniospinal radiotherapy.

Methods

An 83-item web-based survey was developed. An introductory email was sent to 505 physicians and child-life specialists with expertise in pediatric anesthesia and/or affiliated with pediatric radiation oncology departments.

Results

The response rate was 128/505 (25%) and included specialists from Africa (5, 4%), Asia (18, 14%), Australia/Oceania (5, 4%), Europe (45, 35%), North America (50, 39%), and South America (5, 4%). The 128 respondents included 91 anesthesiologists (71%), 20 physicians who were not anesthesiologists (16%), 14 child life/social education specialists (11%), one radiotherapist, one pediatric radiation nurse, and one non-specified medical professional (all = 2%). Of the 128 respondents, 95 (74%) used anesthesia or sedation to facilitate repetitive cranial or craniospinal radiotherapy. Overall, total intravenous anesthesia without intubation was preferred by 67 of 95 (71%) specialists during one or more forms of radiotherapy. During photon-based radiotherapy, total intravenous anesthesia without intubation was the preferred anesthetic method with the patient in the supine (57/84, 68%) and prone positions (25/40, 63%). Propofol was the most used anesthetic agent for both supine (73/84, 87%) and prone positions (38/40, 95%). For proton radiotherapy, total intravenous anesthesia without intubation was the most preferred anesthetic method for the supine (32/42, 76%) and prone treatment positions (11/18, 61%), and propofol was the most used anesthetic (supine: 40/43, 93%; prone: 16/18, 89%).

Conclusions

In this survey of 95 specialists responsible for anesthesia or sedation of children undergoing repetitive cranial or craniospinal radiotherapy, propofol-based total intravenous anesthesia without intubation was the preferred anesthetic technique.

Risk of Intraoperative Hyperthermia and Outcomes in Adults Undergoing Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) is commonly used to treat peritoneal surface malignancies. We aimed to identify risk factors of intraoperative patient hyperthermia and the postoperative outcome of adults undergoing HIPEC PATIENTS AND METHODS: A retrospective, IRB approved, single center cohort study was conducted. Adults treated with cytoreductive surgery and HIPEC between 2006 and 2021 were included. The primary outcome was bladder hyperthermia during perfusion, stratified by severity and duration. Secondary outcomes were postoperative complications and recurrence-free (RFS) and overall (OS) survival. Multivariable logistic regression models were fit to estimate the effects of important covariates.

RESULTS

Out of 214 patients, 114 had mild hyperthermia (≥ 38 °C) at any time, and in 73 of these it lasted for ≥ 30 min. Independent prognostic factors of mild hyperthermia ≥ 30 min were age (OR = 0.958, 95% CI 0.933-0.984), body mas index (BMI; OR = 0.959 95% CI 0.917-1.002), gender (OR = 0.199, 95% CI 0.092-0.431), and type of chemotherapy [cisplatin versus mitomycin (OR = 0.186, 95% CI 0.070-0.491; oxaliplatin versus mitomycin (OR = 0.430, 95% CI 0.163-1.139)]. Prognostic factors of moderate-to-severe hyperthermia (≥ 39 °C) at any time were perfusion duration (OR = 1.094, 95% CI 1.018-1.177) and blood transfusion (OR = 5.689, 95% CI 1.784-18.137). Intraoperative hyperthermia was not associated with increased postoperative complications but was associated with better RFS and OS.

CONCLUSIONS

Our study demonstrates age, gender, BMI, and chemotherapy type to be associated with hyperthermia ≥ 38 °C for ≥ 30 min, whereas longer perfusion time and blood transfusion were associated with hyperthermia ≥ 39 °C. Mild hyperthermia at the end of perfusion is associated with better RFS and OS.

Impact of Ketamine on Opioid Use and Persistent Pain After Cytoreductive Surgery with Hyperthermic Chemotherapy

Background

Persistent pain and opioid use can be devastating after cytoreductive surgery (CRS) and hyperthermic intraoperative chemotherapy (HIPEC).

Methods

We conducted a retrospective study to investigate the impact of ketamine use on postoperative complications and persistent and chronic pain after CRS-HIPEC.

Results

Ketamine reduced perioperative opioid use before and after implementation of recovery after surgery programs. Ketamine did not impact the formation of persistent and chronic pain formation and long-term opioid use. Postoperative complications and postoperative re-operations were independent predictors of persistent pain. Interestingly, the risk of having a complication was increased by 1% for every doubling in opioids used intraoperatively.

Conclusion

Ketamine use reduces perioperative opioid consumption in patients undergoing CRS-HIPEC, but it is not associated with improvements in long-term opioid use and chronic pain.

The quantra hemostasis analyzer compared to thromboelastography (TEG) in the surgical oncologic population: A prospective observational trial

BACKGROUND

Management of coagulopathy during major oncologic surgery can be multifactorial and challenging. Viscoelastic assays (VEAs) can be useful in providing vital data about the mechanism of coagulopathy in these dynamic circumstances.

OBJECTIVES

A prospective nonrandomized observational study with the aim of describing the coagulation parameters of patients undergoing major oncologic surgery using the Quantra® and TEG® 5000 systems. Our secondary objectives included the correlation between Quantra and TEG parameters, and the times to result for both technologies.

METHODS

This study included 74 adults undergoing oncologic surgery with an anticipated blood loss of more than 500 ml. For each subject, whole blood samples for each device were collected at multiple points perioperatively for comparison.

RESULTS

Correlation coefficients between Quantra and TEG parameters were 0.8 and above, indicating a very strong correlation (p < .001). Correlation coefficients between conventional laboratory tests and Quantra ranged from 0.74 to 0.83, indicating a moderate correlation (p < .001). The mean time to obtain results and total processing time was shorter for Quantra in comparison to TEG.

CONCLUSIONS

Quantra parameters strongly correlated with TEG parameters; however, Quantra parameters were available in shorter amount of time as it is specifically designed as a closed point of care device.

The Impact of Thoracic Epidural Analgesia Versus Four Quadrant Transversus Abdominis Plane Block on Quality of Recovery After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Surgery: A Single-Center, Noninferiority, Randomized, Controlled Trial

BACKGROUND

Recovery after CRS-HIPEC influenced by several factors, including pain and opioid consumption. We hypothesized that 4Q-TAP blocks provide not inferior quality of recovery compared with TEA after CRS-HIPEC. We conducted a randomized, controlled trial to determine whether 4-quadrant transversus abdominis plane (4Q-TAP) block analgesia was noninferior to thoracic epidural (TEA) among patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS HIPEC).

METHODS

Patients 18 years or older who underwent a CRS-HIPEC surgery were randomly assigned to have either TEA or 4Q-TAP blocks. The primary outcome of this study was the change in quality of recovery 2 days after surgery. Secondary outcomes included quality of recovery on Days 1, 3, 5, 7, 10, and 30 postoperatively, opioid consumption, pain intensity, length of stay, and postoperative complications. Analyses were performed on a per-protocol basis.

RESULTS

Sixty-eight patients were included in the analysis. The difference between 4Q-TAP and TEA in the mean QoR-15 change from surgery at postoperative Days 1, 2, and 3 was 0.80 (P = 0.004), -4.5 (P = 0.134), and 3.4 (P = 0.003), respectively. All differences through postoperative day 30 were significantly within the noninferiority boundary of -10 except at postoperative Day 2 (P = 0.134). Length of stay, opioid-related adverse events, and frequency and grade of complications were not significantly different between TEA and 4Q-TAP patients.

CONCLUSIONS

Despite the significantly higher use of opioids after CRS-HIPEC in patients with 4Q-TAP blocks, their short-term quality of recovery was not inferior to those treated with TEA. Patients undergoing CRS-HIPEC can be effectively managed with 4Q-TAP blocks.

External tracheal manipulation for bronchial blocker placement in children undergoing thoracic surgery requiring one lung ventilation: A case report

Limited options exist for pediatric one lung ventilation (OLV). Compared to adults, pediatric OLV can be more challenging due to physiological/anatomical differences, various pathologies, and size limitations of lung isolation devices. Fiberoptic bronchoscopy can be harder due to the restricted tube sizes through which bronchial blockers (BB) and scopes can appropriately fit, while providing adequate oxygenation and ventilation. Recent literature is sparse concerning facilitation of BB placement in children. A 2-, 8-, and 10-year-old presented for thoracic surgeries requiring OLV. External tracheal manipulation (ETM) facilitated BB placement in each case and can potentially offer unique advantages in pediatric OLV.

Persistent and Chronic Postoperative Opioid Use in a Cohort of Patients with Oral Tongue Squamous Cell Carcinoma

BACKGROUND

Recently, the concept of persistent postsurgical opioid use has been described for patients undergoing cancer surgery. Our hypothesis was based on the premise that patients with oral tongue cancer require high dosages of opioids before, during, and after surgery, and thus a large percentage of patients might develop persistent postsurgical opioid use.

METHODS

After institutional review board approval, we conducted a retrospective study that included a cohort of patients with oral tongue cancers who underwent curative-intent surgery in our institution. Multivariable logistic regression models were fit to study the association of the characteristics of several patients with persistent (six months after surgery) and chronic (12 months after surgery) postoperative opioid use.

RESULTS

A total of 362 patients with oral tongue malignancies were included in the study. The rate of persistent use of opioids after surgery was 31%. Multivariate analysis showed that patients taking opioids before surgery and those receiving adjuvant therapy were 2.9 and 1.78 times more likely to use opioids six months after surgery. Fifteen percent of the patients were taking opioids 12 months after surgery. After adjusting for clinically relevant covariates, patients complaining of moderate tongue pain before surgery and those taking opioids preoperatively had at least three times higher risk of still using these analgesics one year after surgery.

CONCLUSIONS

Patients with oral tongue cancers have a high risk of developing persistent and chronic postsurgical opioid use.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.

Patterns and predictors of outpatient opioid use after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Background: Long-term opioid use is a well-known complication after surgery. In this retrospective study of adults who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), we sought to determine the rates and factors associated with outpatient opioid use within the sixth and twelfth postoperative months. Methods: Records of 288 opioid-naïve patients were included. Logistic regression models were used to determine factors prognostic of outpatient opioid use. Results: The median patient age was 54 years, and 63% were female. Rates of outpatient opioid use within the sixth and twelfth postoperative months were 21 and 13%, respectively. In the multivariate analysis, every doubling in the amount of in-hospital postoperative opioid consumption was associated with a 44% increase in odds of opioid use within the sixth postoperative month (OR 1.44, 95% CI 1.11-1.87, p = .006) and a 70% increase within the twelfth postoperative month (OR 1.70, 95% CI 1.70-2.37, p = .001). Other factors associated with opioid use within the sixth postoperative month included physical status (OR 5.26, 95% CI 1.08-25.55, p = .039) and recent additional surgery (OR 23.02, 95% CI 2.03-261.30, p = .011). Age (OR 4.39, 95% CI 1.77-10.89, p = .001) and tumor grade (OR 3.31, 95% CI 1.31-8.41, p = .012) were associated with opioid use within the twelfth postoperative month. Conclusion: In this study, the amount of in-hospital postoperative opioid consumption was an important contributory factor to outpatient opioid use in the sixth and twelfth postoperative months. Synopsis In this study of adults who had undergone CRS-HIPEC, higher postoperative opioid consumption during hospitalization was associated with higher odds of opioid use within the sixth and twelfth postoperative months.

A retrospective evaluation of the impact of patient ethnicity on the use of epidural analgesia or blood transfusions in children undergoing major oncologic surgery

Background

The impact of patient ethnicity on healthcare delivery is well documented. In this study of children who had undergone open abdominal or pelvic surgery for tumor resection, we sought to compare the use of epidural analgesia or intraoperative blood transfusions between Caucasian and non-Caucasian children.

Methods

A retrospective study of 139 children was performed. Logistic regression models were used to evaluate the association between the specified perioperative factors and patient ethnicity.

Results

The average age (standard deviation) was 11 years (± 5), 50% were female, and 58% were Caucasian. Compared to Caucasian children, non-Caucasian children were younger (difference in mean, − 2.6 years; 95% confidence interval [− 4.3, − 0.9], p = 0.003), underwent shorter procedures (difference in mean anesthesia minutes, − 134; 95% confidence interval [−  230, − 39], p = 0.006), and had a lower proportion of patients who received epidural analgesia (66% versus 81%, p = 0.042) or blood transfusions (48% versus 65%, p = 0.039). In the adjusted model, patient ethnicity was not associated with the receipt of epidural analgesia (odds ratio 0.53, 95% confidence interval [0.23, 1.21], p = 0.132) or blood transfusions (odds ratio 0.77, 95% confidence interval [0.29, 2.04], p = 0.600). The use of epidural analgesia or blood transfusions was associated with abnormal coagulation factors (odds ratio 0.32, 95% confidence interval [0.14, 0.71], p = 0.005) and the duration of surgery (odds ratio 1.007, 95% confidence interval [1.005, 1.009], p < 0.001), respectively.

Conclusion

In this study of children who had undergone major oncologic surgery, the use of epidural analgesia or blood transfusions was not associated with patient ethnicity.

An assessment of the survival impact of multimodal anesthesia/analgesia technique in adults undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a propensity score matched analysis

BACKGROUND

Studies suggest volatile anesthetics and opioids may enhance the malignant potential of cancer cells. The objective of this single institution retrospective study was to evaluate the survival impact of a multimodal opioid-sparing nonvolatile anesthetic technique (MA) in a group of patients who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for appendiceal carcinomatosis.

METHODS

Propensity score matching (PSM) and Cox proportional hazard models were used to compare the survivals of patients who received MA (MA group), to those who received volatile-opioid anesthesia (volatile-opioid group).

RESULTS

Of the 373 patients, 110 (29%) were in the MA group and 263 (71%) in the volatile-opioid group. The MA group was older (mean ± standard deviation (SD): 55 ± 11 versus 53 ± 10 years, p = .035) and had more patients with ASA scores 3 or 4 (90% versus 81%, p = .032), and those with high grade tumors (18% versus 12%, p = .009). Intraoperative opioid consumption was lower in the MA group (mean morphine equivalents ± SD: 13 ± 10 versus 194 ± 789, p < .0001). After PSM, 107 patients remained in each group. In the adjusted Cox proportional hazards model after PSM, MA was not associated with improved progression free survival (PFS) (HR 1.45, 95% CI [0.94-2.22], p = .093) or overall survival (OS) (HR 1.66, 95% CI [0.86-3.20], p = .128), when compared to volatile-opioid anesthesia.

CONCLUSIONS

In this retrospective study, a multimodal opioid-sparing nonvolatile anesthetic approach was not associated with improved survival. Precis' statement: In this study of patients undergoing major cancer surgery, the use of multimodal anesthetic and analgesic agents, while avoiding volatile anesthetics and minimizing opioid use was not associated with improved survival.

An analysis of the survival impact of dexmedetomidine in children undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

OBJECTIVE

Recent evidence suggests the α2-adrenoreceptor agonist dexmedetomidine may promote metastasis of cancer cells. In this study we sought to evaluate the impact of dexmedetomidine administration on the survival of children and adolescents with cancer.

DESIGN

Retrospective chart review.

SETTING

Comprehensive cancer center.

PATIENTS

Children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis.

INTERVENTION

Intraoperative and/or early postoperative (within 24 hours of surgery) administration of dexmedetomidine.

MEASUREMENTS

Multivariable cox proportional hazard models were used to assess the association between dexmedetomidine administration and progression free survival (PFS) or overall survival (OS).

MAIN RESULTS

Ninety-three patients were identified. The median age was 12 years, 42% were female, and 35% received dexmedetomidine. There were no significant differences between the baseline and perioperative characteristics of patients who received dexmedetomidine and those who did not. In the multivariable analysis, the administration of dexmedetomidine was not associated with PFS (HR = 1.20, 95% CI [0.60-2.41], p = .606) or OS (HR = 0.81, 95% CI [0.35-1.85], p = .611).

CONCLUSION

In this retrospective study of children and adolescents who had undergone a major oncologic surgery, the intraoperative and/or early postoperative administration of dexmedetomidine was not associated with survival.

Perioperative factors associated with persistent opioid use after extensive abdominal surgery in children and adolescents: A retrospective cohort study

BACKGROUND

In adults, preoperative opioid use and higher perioperative opioid consumption have been associated with higher odds of persistent opioid use after surgery. There are limited data on the prevalence and factors associated with persistent opioid use after major oncologic surgery in children.

AIMS

In this study, we sought to determine the prevalence and factors associated with the development of persistent opioid use in a group of children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

METHODS

A retrospective study of patients ≤19 years of age was performed. Univariable logistic regression was used to assess factors associated with a postdischarge persistent opioid use of up to 6 months.

RESULTS

Eighty-six children were identified. The median age was 12 years, and 43% were female. The proportion of patients with persistent opioid use over the immediate 3, 6, 12 and 24 postdischarge months was 54/77 (70%), 18/51 (35%), 13/45 (29%), and 3/24 (13%), respectively. The daily average in-patient pain scores were higher in the group of children who subsequently developed persistent opioid use of up to 6 months (estimated difference 0.5, 95% confidence interval [CI]: 0.3, 0.8, P < .01). Furthermore, higher postoperative opioid consumption was associated with greater odds of a subsequent persistent opioid use of up to 6 months (odds ratio 1.03, 95% CI: 1.00, 1.07, P = .05).

CONCLUSION

In this retrospective study of children and adolescents who had undergone a major oncologic surgery, higher in-patient pain scores and higher postoperative opioid consumption were associated with a persistent opioid use of up to 6 months.

Identification of risk factors associated with postoperative acute kidney injury after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a retrospective study

BACKGROUND

Acute kidney injury (AKI) is a postoperative complication associated with significant morbidity and mortality. The incidence and risks factors for AKI after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been fully studied. The purpose of this study was to identify perioperative risk factors predictive of AKI after CRS-HIPEC.

METHODS

This retrospective study collected demographic, tumour-related, intraoperative and postoperative data from 475 patients who underwent CRS-HIPECs. AKI was defined using the acute kidney injury network criteria and calculated on postoperative days 1, 2, 3, 7 and day of hospital discharge. We conducted univariate and multivariate analyses to assess the association between variables of interest and AKI. A p value of <0.05 was considered statistically significant.

RESULTS

The incidence of AKI was 21.3%. The multivariate analysis identified six predictor factors independently associated with the development of AKI (OR: [95%CI]); age: 1.16 (1.05-1.29, p < 0.005), BMI (overweight: 1.97 [1.00-3.88], p = 0.05) and obesity: 2.88 (1.47-5.63), p < 0.002)), preoperative pregabalin: 3.04 (1.71-5.39, p < 0.037), platinum-based infusion: 3.04 (1.71-5.39, p < 0.001) and EBL: 1.77 (1.27-2.47, p < 0.001). Splenectomy had a protective effect (OR: 0.44 (0.25-0.76, p < 0.003).

CONCLUSIONS

Our study demonstrates that the incidence of AKI is high. While other studies have reported that AKI is associated with platinum-based infusion, age and obesity, we report for the first time a negative association between pregabalin use and AKI. More studies are needed to confirm our results.

Assessing the survival impact of perioperative opioid consumption in children and adolescents undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND

Several studies in adult patients have suggested an unfavorable association between opioid consumption and cancer progression.

AIMS

This study investigated the impact of opioid consumption on the survival of children and adolescents undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

METHODS

A retrospective study of patients <19 years who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was performed. Univariate and multivariate Cox proportional hazard analyses were used to identify factors associated with recurrence-free survival and overall survival.

RESULTS

Seventy-five patients were identified. Median age was 11.6 years (range, 1.8-18.9), and 43% was female. Median perioperative opioid consumption was 18.9 morphine dose equivalents per kilogram (range, 0.6-339.6). There was no statistically significant association between opioid consumption and recurrence-free survival [hazard ratio, 1.00; 95% confidence interval, (0.99-1.02), P = 0.55] or overall survival [hazard ratio 1.01; 95% confidence interval (0.99-1.03), P = 0.22]. Independent prognostic factors associated with poor survival included incomplete cytoreduction and extra-abdominal disease.

CONCLUSION

In this retrospective study of children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, there was no statistically significant association between opioid consumption and recurrence-free survival or overall survival.

Beat to Beat: A Measured Look at the History of Pulse Oximetry

It can be argued that pulse oximetry is the most important technological advancement ever made in monitoring the well-being and safety of patients undergoing anesthesia. Before its development, the physical appearance of the patient and blood gas analysis were the only methods of assessing hypoxemia in patients. The disadvantages of blood gas analysis are that it is not without pain, complications, and most importantly does not provide continuous, real-time data. Although it has become de rigueur to use pulse oximetry for every anesthetic, the road leading to pulse oximetry began long ago.

Unanticipated Compression of the Trachea in a 5-Month-Old Undergoing an MRI for Evaluation of Neurofibromatosis

Neurofibromatosis type 1 is an autosomal-dominant disorder with the tendency toward the formation of tumors. Plexiform neurofibromas are the most common type of tumors seen in neurofibromatosis type 1. Approximately 50% occur in the head and neck region with a 5% incidence of airway involvement. We describe the case of a 5 month old with a plexiform neurofibroma of the neck who developed complete airway obstruction on induction of anesthesia. Magnetic resonance imaging revealed a skull base neurofibroma extending to the hypopharynx and resulting in deviation of the airway. Because of the possibility of airway involvement, a careful preanesthetic evaluation as well as a slow induction with the maintenance of spontaneous ventilation should be considered in patients presenting with facial neurofibromas.

Investigating the association between perioperative blood transfusions and outcomes in children undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND AND OBJECTIVES

Studies indicate the perioperative transfusion of red blood cells during oncologic surgery may be associated with worse outcomes. In this study, we evaluated the impact of red blood cell transfusions on the short- and long-term outcomes of children undergoing a major oncologic surgery.

MATERIALS AND METHODS

A retrospective review of the medical records of children ≤18 years of age who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was performed. Univariate and multivariate analyses were performed to identify factors influencing survival, complications and length of stay.

RESULTS

Seventy-five children were identified, 80% of whom had received a red blood cell transfusion. Children who received a red blood cell transfusion had a significantly longer length of stay (P = 0·0003). However, the association between red blood cell transfusions and recurrence-free survival (HR: 1·307, 95% CI: 0·547-3·124; P = 0·55), overall survival (HR: 1·487, 95% CI: 0·585-3·780; P = 0·40) or the incidence of major complications (27·8 vs. 0% in non-transfused children, P = 0·18) was not statistically significant.

CONCLUSION

This retrospective study of children undergoing major oncologic surgery did not demonstrate a significant association between red blood cell transfusions and worse outcomes.

Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases

BACKGROUND

Extensive peritoneal metastatic disease is rare in children. Although usually manifested as carcinomatosis in adults, sarcomatosis is more common in children. The authors began a pediatric hyperthermic intraperitoneal chemotherapy (HIPEC) program, and this report describes their initial results from the first 50 pediatric, adolescent, and young adult patients.

METHODS

A single-institution, retrospective study investigated the first 50 cytoreductive surgeries and HIPEC by one surgeon for patients 3-21 years of age. The HIPEC was added to chemotherapy and radiotherapy treatment. Demographics, outcome, and complications were recorded.

RESULTS

The median follow-up period for the surviving patients was 21.9 months. The most common diagnoses were desmoplastic small round cell tumor (n = 21), rhabdomyosarcoma (n = 7), mesothelioma (n = 4), and other carcinoma (n = 17). Multivariate analysis showed that patients treated with HIPEC and an incomplete cytoreduction had a greater risk for recurrence than those who had a complete cytoreduction (p = 0.0002). The patients with a higher peritoneal cancer index (PCI) (i.e., a large tumor burden) had a median overall survival (OS) time of 19.9 months relative to the patients with a lower PCI score, who had a median OS of 34 months (p = 0.049). The patients without complete cytoreduction had a median OS of 7.1 months compared with 31.4 months for the patients with complete cytoreduction (p = 0.012). No perioperative mortalities occurred. The incidence of major complications was 28 %.

CONCLUSION

Cytoreductive surgery and HIPEC with a programmatic approach for patients 3-21 years of age is unique. The best outcome was experienced by patients with desmoplastic small round cell tumor and those with complete cytoreduction. Complete cytoreduction for patients without disease outside the abdominal cavity at the time of surgery affords the best outcome.

Chemotherapy-induced cardiovascular toxicity: beyond anthracyclines

It is not uncommon for anesthesiologists to encounter cancer patients who have received chemotherapy agents known to cause cardiovascular toxicities such as heart failure, systemic hypertension and thromboembolic events. Anthracyclines have been for several decades the most studied agents because of their known cardiovascular effects and relatively high incidence of heart failure. However, cancer patients are currently treated with newer chemotherapeutics such as imatinib, sunitinib, trastuzumab and bevacizumab that are also responsible of causing cardiovascular toxicities. The type of cardiotoxicity associated with these newer agents (type II cardiotoxicity) appears to be different in terms of pathogenesis to that caused by anthracyclines (type I cardiotoxicity). Thus, anesthesiologist needs to be aware of the clinical features of each type of cardiac toxicity. This review will summarize the current clinical evidence on cardiovascular toxicity induced by chemotherapeutic agents and will try to shed light on the current information regarding the perioperative management of patients with chemotherapy-induced cardiovascular toxicity.

Non-invasive anesthesia for children undergoing proton radiation therapy

BACKGROUND

Proton therapy is a newer modality of radiotherapy during which anesthesiologists face specific challenges related to the setup and duration of treatment sessions.

PURPOSE

Describe our anesthesia practice for children treated in a standalone proton therapy center, and report on complications encountered during anesthesia.

MATERIALS AND METHODS

A retrospective review of anesthetic records for patients ⩽18years of age treated with proton therapy at our institution between January 2006 and April 2013 was performed.

RESULTS

A total of 9328 anesthetics were administered to 340 children with a median age of 3.6years (range, 0.4-14.2). The median daily anesthesia time was 47min (range, 15-79). The average time between start of anesthesia to the start of radiotherapy was 7.2min (range, 1-83min). All patients received Total Intravenous Anesthesia (TIVA) with spontaneous ventilation, with 96.7% receiving supplemental oxygen by non-invasive methods. None required daily endotracheal intubation. Two episodes of bradycardia, and one episode each of; seizure, laryngospasm and bronchospasm were identified for a cumulative incidence of 0.05%.

CONCLUSIONS

In this large series of children undergoing proton therapy at a freestanding center, TIVA without daily endotracheal intubation provided a safe, efficient, and less invasive option of anesthetic care.

Complete cytoreduction and HIPEC improves survival in desmoplastic small round cell tumor

BACKGROUND

Desmoplastic small round cell tumor (DSRCT) is a rare tumor of adolescents and young adults. Less than 100 cases per year are reported in North America. Extensive peritoneal metastases are characteristic of this disease. We performed cytoreductive surgery and hyperthermic peritoneal perfusion with chemotherapy (HIPEC) using cisplatin (CDDP) for DSRCT.

METHODS

A retrospective cohort study was performed on 26 pediatric and adult patients who underwent cytoreduction/HIPEC using CDDP for DSRCT at a single cancer center. Neoadjuvant chemotherapy, adjuvant chemotherapy, and postoperative enteral nutrition were given to all patients. Postoperative radiation therapy was given to most patients. Follow-up was from 6 months to 6 years. Outcome variables were evaluated for disease-free and overall survival (OS).

RESULTS

Five patients (19 %) were less than 12 years of age at surgery. Patients who had disease outside the abdomen at surgery had a larger risk of recurrence or death than those who did not (p = 0.0158, p = 0.0393 time from surgery to death respectively). Age, liver metastasis, and peritoneal cancer index level did not significantly predict disease-free or OS. Patients who had CR0 or CR1 and HIPEC had significantly longer median survival compared with patients who had HIPEC and CR2 cytoreduction (63.4 vs. 26.7 months).

CONCLUSIONS

HIPEC may be an effective therapy for children and young adults with DSRCT. Patients with DSRCT require complete cytoreduction before HIPEC to optimize outcome. Patients with DSRCT and disease outside the abdomen at the time of surgery do not benefit from HIPEC.

Safety of epidural analgesia in the perioperative care of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND

The perioperative coagulopathy, hemodynamic instability, and infectious complications that may occur during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has raised concerns about the safety of epidural analgesia in patients undergoing such procedures.

METHODS

We conducted a retrospective review of the perioperative anesthetic management of 215 adult patients who had undergone CRS with HIPEC with epidural analgesia. We reviewed epidural-related complications and analyzed the effect of early initiation of continuous epidural analgesia on estimated blood loss, intraoperative fluid administration, blood transfusion and vasopressor requirements, time to extubation, and length of stay.

RESULTS

No epidural hematomas or abscesses were reported. Two patients (0.9 %) had delays in epidural removal because of thrombocytopenia, and two had epidural-site erythema (0.9 %). The majority of postoperative epidural-related hypotensive episodes were successfully treated with fluid boluses. Early initiation of epidural analgesic infusions (before HIPEC) was associated with significantly less surgical blood loss and fluid requirements (P = 0.005 and 0.02, respectively). Pre-HIPEC initiation of epidural infusions was not associated with a statistically significant difference in the following: volume of blood transfused, intraoperative vasopressors use, time to extubation, and length of hospital stay.

CONCLUSIONS

With close hematologic monitoring and particular attention to sterility, epidural analgesia can be safely provided to patients undergoing CRS with HIPEC. Early initiation of continuous epidural infusions during surgery could lead to decreased blood loss and less intraoperative fluid administration. Prospective randomized studies are required to further investigate these potential benefits.

Anesthetic management and renal function in pediatric patients undergoing cytoreductive surgery with continuous hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin

BACKGROUND

Extensive tumor implants secondary to sarcoma, sarcomatosis, or mesothelioma in children is rare. We conducted the first phase 1 trial of escalating doses of cisplatin during hyperthermic intraperitoneal chemotherapy (HIPEC) in children with sarcomatosis. The most devastating complication of cisplatin therapy is nephrotoxicity. Here we present the anesthetic management and analysis of the impact of intraoperative fluid management on the incidence of renal failure.

METHODS

Of the 10 patients under 18 years of age who underwent HIPEC in the context of our phase 1 trial, six patients were under the age of 10 years. We reviewed the anesthetic management, intraoperative fluid and blood administration, and postoperative renal function in these patients.

RESULTS

The average age and weight were 6 years and 20.9 kg, respectively. To avoid renal toxicity, urine output was maintained at an average of 3 ml/kg/h. Crystalloid and colloid were transfused at an average rate of 9 ml/kg/h. Percentage increase in creatinine postoperatively varied from 33 to 500 %. Volume of fluid administered did not correlate with percentage increase in creatinine. All patients had a temporary increase in their serum creatinine, but none required dialysis.

CONCLUSIONS

Fluid administration at an average rate of 9 ml/kg/h was required to maintain satisfactory urine output. This rate of intraoperative fluid administration is similar to what is provided to adult HIPEC patients. There was no significant correlation in the volume or type of fluid delivered and the increase in serum creatinine. More studies are needed to determine optimal fluid management in children undergoing HIPEC with cisplatin.