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Anaesthesia considerations and Implications during Oncologic and Non-Oncologic surgery in Cancer patients

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Cancer has been the leading cause of mortality in both developed and developing countries. With the advancement in chemotherapeutic agents, the quality and lifespan of patients with advanced malignancies has improved. These patients often come to hospitals for various types of elective and emergency surgeries. The attending anaesthesiologist faces a daunting task while managing these patients as there can be gross physiological derangements in most of the organ systems. A careful and thorough preoperative assessment, optimisation of physiological milieu, vigilant intraoperative monitoring, anticipation of potential complications and postoperative pain control is essential for reducing perioperative mortality and morbidity in these patients.







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Anaesthesia considerations and Implications during Oncologic and Non-Oncologic surgery in Cancer patients

  1. 1. Anaesthesia considerations and Implications during Oncologic and Non-Oncologic surgery in Cancer patients
  2. 2. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Theme Symposium Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients Sukhminder Jit Singh Bajwa a,*, Ashish Kulshrestha b a Associate Professor, Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India b Assistant Professor, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India article info abstract Article history: Cancer has been the leading cause of mortality in both developed and developing coun- Received 24 June 2012 tries. With the advancement in chemotherapeutic agents, the quality and lifespan of pa- Accepted 13 February 2013 tients with advanced malignancies has improved. These patients often come to hospitals Available online xxx for various types of elective and emergency surgeries. The attending anaesthesiologist faces a daunting task while managing these patients as there can be gross physiological Keywords: derangements in most of the organ systems. A careful and thorough preoperative Malignancy assessment, optimisation of physiological milieu, vigilant intraoperative monitoring, Chemotherapeutic agents anticipation of potential complications and postoperative pain control is essential for Anaesthesia reducing perioperative mortality and morbidity in these patients. The toxicity of chemo- Surgery therapeutic agents and potential drug interactions with selected anaesthetic drugs are of prime concern while anaesthetizing such patients. The build-up of nutrition in these patients is essential during preoperative period and should be continued during postoperative period also. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Malignancy has become one of the leading causes of death especially in developed world and even in developing countries; its incidence has increased tremendously over the last few decades. In 2008, it was found that about 12.7 million patients were diagnosed of some form of malignancies worldwide out of which about 7.6 million died of the malignancy itself or its associated complications.1 Malignancy as a group accounts for about 13% of all deaths per year with the most common sites being lung/bronchus, colorectal, breast and prostate.2 The most common types of malignancies found in children are leukaemia (34%), brain tumours (23%) and lymphoma (12%).3 With the advent of newer and advanced chemotherapeutic agents, survival and lifespan of these patients has witnessed a tremendous increase. As a result, large number of these cancer patients during post cancer treatment presents either for surgical intervention for the primary tumour excision or emergency intervention for their various ill effects. Due to multitude of effects of malignancy on various systems in the body and effects of chemotherapeutic agents, these patients pose a great challenge to the attending anaesthesiologist.4 * Corresponding author. House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab 147001, India. Tel.: þ91 (0) 9915025828, þ91 1752352182. E-mail addresses: sukhminder_bajwa2001@yahoo.com, sukhminderbajwa@gmail.com (S.J.S. Bajwa). 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.02.004 Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004
  3. 3. 2 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6 2. Effects of tumour on the body 2.1. Local effects of tumours Tumours of head, neck and pose significant problems in maintenance of airway especially after induction of anaesthesia due to their extrinsic compressive effects or may be due to presence of intrinsic tumour.5 Preoperatively, radiographic examination of soft tissues of neck and computed tomography of neck is mandatory in these patients for careful preoperative planning for securing an unobstructed airway. Planned awake fibreoptic guided intubation may be required in tumours with extrinsic compression on airway and a preoperative tracheostomy may be required in patients with an anticipated difficult fibreoptic intubation due to presence of large vascular tumour inside the airways. Postoperatively these patients can be at risk of airway compromise due to oedema of larynx and neck structures which may warrant continuing the mechanical ventilation in these patients till the airway oedema subsides. Superior vena cava syndrome may develop in primary lung malignancy due to obstruction of venous return from the head and neck by the tumours. It may be an acute or subacute process and results in facial oedema, plethora, dilatation of veins of chest wall and neck, headache, conjunctival oedema, respiratory difficulty, visual disturbances and altered level of consciousness. Diagnosis is usually clinical or by non-invasive venous studies. Therapy includes administration of thrombolytic agents and/or emergent radiotherapy in patients with airway compromise.6 Pericardial effusion and cardiac tamponade are rare due to the primary tumours of pericardium but are usually due to metastasis to the pericardium. Acute accumulation of as little as 100 ml of fluid in pericardial cavity can lead to tamponade and cardiovascular collapse while chronic accumulation of large volumes of fluid can be accommodated inside the pericardial cavity due to the stretching of the pericardium. Echocardiography is the investigation of choice and can detect as little as 15 ml of pericardial fluid.7 Treatment depends on the degree of haemodynamic compromise and can involve pericardiocentesis or pericardiectomy depending on the aetiology of diffusion and its likely recurrence. 2.2. Systemic effects of tumour Pain is a common symptom in patients with malignant tumours with an incidence of 25% in newly diagnosed malignancies and upto 75% in advanced disease.8 It may be due to involvement of somatic nerves by tumour itself or by the systemic metastasis. These patients can present for various procedures for relief of chronic pain like nerve blocks, ganglion blocks etc. Majority of patients with advanced malignancy present with cachexia which is characterised by significant weight loss, anorexia, weakness, poor performance and impaired immune function.9 These cachectic patients pose significant challenges to the attending anaesthesiologist due to their disturbed homoeostasis Renal failure can develop in cancer patients by both prerenal as well as intrinsic renal mechanisms. However, preexisting renal and renal endocrine disorders can be more challenging in such patients.10 Pre-renal causes include dehydration due to cachexia or poor oral intake and intrinsic renal causes includes sepsis syndrome or use of nephrotoxic chemotherapeutic agents. Post-renal failure also is likely in obstruction of renal outflow tract by pelvic tumours, prostate or cervical malignancies.11 Infection is a common and unfavourable effect of malignancy which is mainly contributed by depressed immunologic function due to neutropenia. It may occur due to malignancy interfering with bone marrow functions or may be due to drug induced myelosuppression. These nosocomial infections increase hospital stay and the cost to patient.12 A characteristic constellation of systemic symptoms termed as ‘paraneoplastic syndrome’ can occur due to secretion of various hormones from the primary tumour into the circulation which causes various metabolic abnormalities like myasthenic syndrome in thymoma, syndrome of inadequate secretion of antidiuretic hormone (SIADH) seen in small cell carcinoma bronchus and so on.13 Electrolyte abnormalities usually develop in malignancy, the commonest being hypercalcaemia which develops in about 10% of all malignancies and is due to bony metastasis causing bone resorption. Other abnormality seen is hyponatremia which may develop due to SIADH or due to impaired ability to produce dilute urine. Tumour lysis syndrome is a constellation of symptoms that is associated with cytotoxic therapy of malignancy resulting in various metabolic derangements like hyperuricemia, hypocalcemia, hyperkalemia, hyperphosphatemia and uraemia leading to acute renal failure. It is associated with leukaemia, small cell carcinoma lung, testicular and breast cancer.14 2.3. Haematological effects The haematologic effects of malignancy are due to a primary malignancy of bone marrow (leukaemia), metastasis or myelosuppression due to chemotherapeutic agents. The major haematologic effects seen are: Anaemia is a common finding and suggests chronicity of the disease with significantly low erythropoietin levels due to direct suppression of erythropoietin secreting cells by the malignancy or due to suppressive effects of radiotherapy and chemotherapy.15 Leukopenia is most often associated with the chemotherapeutic treatment of solid tumours and is directly related to the incidence of systemic infections.16 Thrombocytopenia occurring in malignancy is usually due to effects of chemotherapy and radiotherapy on bone marrow function and may also be due to splenic sequestration of platelets because of enlarged spleen. Thrombosis can also occur in about 2e10% of cases of cancer and may be the first indication of an occult malignancy.17 Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004
  4. 4. 3 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6 2.4. Effects of anticancer treatment The treatment of cancer involves selective destruction of malignant cells by both radiation therapy and by chemotherapeutic agents directed against malignant cells. This anticancer therapy has various negative effects on body which may cause debilitating effects on normal body homoeostasis. 1. Effects of radiation therapy: Radiations are used in specific tumours to achieve complete cure and in some tumours to achieve palliation. The ill effects of radiation therapy depend upon the intensity of radiation used.16 The various effects of radiation therapy are18,19: Direct effect of radiation can cause epidermal desquamation and pigmentation which can lead to contractures of irradiated area. Acute radiation enteritis can result due to radiation induced mucositis and is often self-limiting but long term effects can result in strictures, obstruction, perforation and fistula formation, which may require emergency intervention. Acute radiation pneumonitis can develop in lungs resulting in reduced pulmonary compliance and dyspnoea which can lead to pulmonary fibrosis in long term. The nervous system is usually least affected and radiation induced peripheral neuropathy is seen with mixed sensory and motor deficits. Radiation nephropathy can result in proteinuria and hypertension and treatment with angiotensin converting enzyme inhibitors (ACEI) can reduce its severity. The radiation induced cardiac injury usually manifest as mild pericarditis and pericardial effusion after 6 months of therapy. The hepatic injury can occur as an acute reaction within 2e6 weeks of initiation of therapy with hepatic enlargement and portal hypertension and abnormal liver function tests whereas a chronic form occurring after 6 months usually results in progressive cirrhosis. Radiation therapy causes swelling and oedema of soft tissues of head and neck which can later result in fibrosis posing difficulties in intubation of these patients. 2. Effects of chemotherapy: With recent advancement in chemotherapeutic agents, more number of cancer patients are being treated with these agents. Apart from their cytotoxic effects on malignant cells, they also have toxic effects on normal body cells which cause their sideeffects.20,21 The various chemotherapeutic agents with their side-effects are summarised in Table 122: 3. Anaesthetic considerations in patients with cancer The patients with malignancy can present with myriad of physiological alterations in body systems which place these patients at an extra risk during the perioperative period as compared to the normal population. These patients can present for various surgeries for resection of primary tumour, diagnostic procedures for unknown primary or emergency surgery for complication of malignancy. The risks increase to a greater extent if such patients present with untreated comorbid diseases.23 The anaesthetic management of these patients require a sound knowledge of the various physiological alterations and should involve: 3.1. Preoperative assessment A thorough preoperative assessment is mandatory to know the physical status of the patient, the stage of malignancy and the risk involved with the surgery. The assessment of the nutritional status of the patient is essential as these patients are often poorly nourished because of the malignancy. The build-up of nutritional state is mandatory for a positive postoperative outcome and can be achieved with hyperalimentation or parenteral nutrition. Due to the physiological alterations in patients with malignancy, these often have electrolyte abnormalities which should be corrected preoperatively for better intra and postoperative haemodynamic stability. Assessment of cardiopulmonary reserve is very essential as the cardiovascular system is often involved by the primary malignancy, metastatic disease or by the radiotherapy or chemotherapeutic agents. Any involvement of cardiovascular system should prompt to undergo echocardiography and exercise stress testing and further invasive testing with angiography should be considered in specific conditions.24 Several endocrine abnormalities exist in these patients including diabetes mellitus, diabetes insipidus, hypopituitarism, thyroid dysfunction, adrenal cortical and medullary Table 1 e Showing various chemotherapeutic agents and their associated side-effects. Class Drugs Side-effects Vinca alkaloids Busulfan, Chlorambucil, Cyclophosphamide, Melphalan, Isofosfamide Methotrexate, Fluorouracil, Gemcitabine, Mercaptopurine Vincristine, Vinblastine, Paclitaxel, Etoposide, Docetaxel Antibiotics Bleomycin, Doxorubicin, Daunorubicin, Mitoxantrone Hormones Tamoxifen, Letrozole, Flutamide, Oestrogen Myelosuppression, uric acid nephropathy, nausea vomiting, hemorrhagic cystitis, carcinogenic, SIADH Myelosuppression, dermatitis, alopecia, pulmonary fibrosis, nephrotoxicity, Autonomic peripheral neuropathy, myelosuppression, dermatitis, cardiotoxicity Pulmonary fibrosis, cardiotoxicity, myelosuppression, dermatitis Myelosuppression, coagulation abnormalities, hemorrhagic cystitis Alkylating agents Antimetabolites Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004
  5. 5. 4 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6 dysfunction, calcium disorders etc.25e28 Preoperative review and management of all these condition is essential for preventing intra and postoperative complications. Such patients may require intensive care monitoring during postop period. Patients having co-morbid psychiatric and psychologic disorders are difficult to treat. The preoperative evaluation is extremely challenging in such patients as the elicitation of proper history and relevant clinical examination is difficult as these patients exhibit a different degree of co-operation during such evaluation.29 A deranged haemogram is often encountered in these patients and any correctable causes of such abnormalities should be identified and appropriately treated for a better postoperative outcome like stem cell stimulation therapy and correcting the coagulation defects.30 As a rule, all patients with malignancy should have extensive preoperative testing which should include complete haemogram, coagulation profile, liver function test, renal function test, electrolytes, 12 lead electrocardiogram and chest radiograph. Airway assessment is of utmost importance to an anaesthesiologist especially in head and neck malignancies to anticipate any intubation difficulties and to develop a plan to overcome such difficulties. 3.2. Intraoperative management Intraoperative management of these patients is as important as the preoperative assessment as these patients are prone to develop serious intraoperative cardiovascular complications due to their disturbed homoeostasis: These patients should be monitored with the standard intraoperative monitors including non-invasive blood pressure, electrocardiogram, pulse oximeter, end-tidal carbon dioxide monitor, temperature probe and urine output. Invasive monitoring should be used wherever the clinical condition of the patient mandates. Intraoperative temperature monitoring is essential to maintain the temperature as these patients are prone to develop hypothermia. Forced convective air warming devices are beneficial in maintaining normothermia to prevent ill effects of hypothermia in the postoperative period.31 Shivering is a very unpleasant phenomenon in postoperative patients. Numerous drugs have been used to control the incidence of postoperative shivering with a varying level of success. Dexmedetomidine is the newer addition to the anaesthesiologist’s armamentarium for control of this postoperative menace.32 As mentioned earlier, airway maintenance in patients with head and neck malignancies is essential and should be planned preoperatively. The decision of awake fibreoptic guided intubation or elective tracheostomy should be based on clinical judgement of the anaesthesiologist. Positioning of the patient is a very important but often neglected part in the intraoperative management of these patients. There are different types of positions which are employed by the surgeons depending upon type of surgery like supine, lateral decubitus, prone etc. The common precautions which should be taken in each of these positions are: - proper padding of all the pressure points, - avoidance of excessive stretching of the nerve plexuses especially in upper limbs, - proper positioning of eyes in prone position to prevent postoperative blindness and - avoidance of compression on abdomen in prone position to facilitate proper ventilation. Blood component therapy in these patients should be guided by clinical judgement. Risk of transmission of infection in these immunocompromised patients should be weighed with the benefits of blood transfusion. A value of 6e8 g/dl for haemoglobin is considered a threshold for patients without any preoperative risk factors and 10e11 g/dl for those with significant risk factors.33 Blood conservation strategies may be employed to prevent excessive intraoperative blood loss like preoperative embolisation of highly vascular tumours and metastases. Intraoperative cell salvage have been controversial as it can increase the risk of spreading the cancerous cells systemically, however use of filtration and irradiation have found some use in reducing tumour load of the salvaged blood.34 Use of antifibrinolytics have been studied recently and have been found to significantly reduce the intraoperative blood loss with reduced need for allogenic blood transfusions and also no significant increased incidence of venous thrombosis have been found.35 Benzodiazepines have been shown to alter the immunological response to stress of surgery by reduction in cytokines release and thus may be beneficial in these patients.36 General anaesthesia have been found to be immunomodulatory in these patients by interfering with functions of immunological cells like natural killer cells (NK), macrophages and can increase the mortality associated with postoperative wound healing.37 However, wherever general anaesthesia is necessary, efforts should be done to administer minimal dose of anaesthetics by addition of adjuvants like dexmedetomidine which definitely decreases the dose of analgesics and anaesthetics.38 Total intravenous anaesthesia is better alternative for a rapid and smooth recovery from anaesthesia.39 Regional anaesthesia alone or combined with general anaesthesia have been found to not only cause reduction of stress response to surgical stress but also to reduce the occurrence of metastasis in advanced malignancies.40e42 Administration of regional anaesthesia should aim at administering minimal dose of local anaesthetics and this can be achieved with addition of adjuvants like dexmedetomidine, fentanyl, clonidine and so on wherever feasible.43e45 However, regional anaesthesia becomes challenging in patients with suspected metastasis to the spine. Elicitation of paraesthesia during administration of epidural regional anaesthesia should prompt one to discard this technique and should resort to general anaesthesia.46 3.3. Postoperative management A careful postoperative monitoring of these patients in a high dependency unit is desirable especially in patients with Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004
  6. 6. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6 significant risk factors. In few patients, the postoperative intensive care becomes essential and such patients have to be shifted to ICU for further management. Prognosis and costs involved in the treatment of such patients should be thoroughly explained to the patient’s relative in their own vernacular.47 Alleviation of acute surgical pain is of utmost importance in the postoperative period with advanced malignancies to reduce the stress response and to aid in proper wound healing. These patients are often on long term oral opioids which should be replaced with parenteral formulations and the dose carefully titrated to the desired effect with an additional 30% of the dose added for the acute postoperative pain over and above the usual dose of opioids.48 The nutritional aspects cannot be ignored at all in these patients especially in preoperative malnourished and aged patients. The nutritional supplements should be continued during the postoperative period whether they are in ward, high dependency units or intensive care units.49 3.4. Thromboprophylaxis Venous thromboembolism is a serious postoperative complication especially in patients with malignancy with an incidence of 45e69% without any prophylaxis. Various mechanical and pharmacological methods can be employed and the incidence of deep vein thrombosis can be reduced to 4%.50,51 The various pharmacological methods are use of warfarin, low-dose heparin, low molecular weight heparin and aspirin. An important implication of use of thromboprophylaxis for anaesthesiologist is when epidural catheter is in place, so that the removal of the catheter should take place at an appropriate time period to prevent development of any epidural haematoma. 4. Conclusion In conclusion, anaesthesia for patients with cancer pose significant challenges due to physiological alterations caused by malignancy itself, due to distant metastasis and also due to endocrine changes brought about by the tumour. A thorough preoperative assessment with correction of nutritional status and electrolyte abnormalities, careful intraoperative planning and monitoring and intensive postoperative monitoring and relief of acute postoperative pain, is essential for a positive outcome of the patient. The effect of anaesthesia on malignancy is a matter of debate and should be consolidated by further randomised controlled studies. Conflicts of interest All authors have none to declare. references 1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69e90. 5 2. Schottenfeld D. Epidemiology. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:494e518. 3. Kaatsch P. Epidemiology of childhood cancer. Cancer Treat Rev. 2010;36(4):277e285. 4. Huettemann E, Sakka SG. Anaesthesia and anti cancer chemotherapeutic drugs. Curr Opin Anaesthesiol. 2005;18:307e314. 5. Bajwa SS, Panda A, Bajwa SK, Singh A, Parmar SS, Singh K. Anesthetic and airway management of a child with a large upper-lip hemangioma. Saudi J Anaesth. 2011;5:82e84. 6. Celak AJ, Roberts J, Meranze SG, Johnson DH. Superior vena cava syndrome. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:811e819. 7. Lake CL. Anesthesia and pericardial disease. Anesth Analg. 1983;62:431e443. 8. Grossman Stuart A, Sheidler VR. Cancer pain. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:539e555. 9. Tisdale MJ. Biology of cachexia. J Natl Cancer Inst. 1997;89:1763. 10. Bajwa SJ, Kwatra I. Reno-endocrinal disorders: a basic understanding of the molecular genetics. Indian J Endocrinol Metab. 2012;16:158e163. 11. Bodey GP. Fever in the neutropenic patients. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:690e706. 12. Eggimen P, Pitted D. Infection control in ICU. Chest. 2001;120:2059e2093. 13. Morton AR, Lipton A. Hypercalcemia. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:719e735. 14. Hande KR, Garrow GC. Acute tumour lysis syndrome in patients with high grade non Hodgkin’s lymphoma. Am J Med. 1993;94:133. 15. Hellman S. Principles of radiotherapy. In: DeVita VT, Hellman S, Rosenberg SA, eds. Cancer Principles and Practice of Oncology. 3rd ed. Philadelphia: JB Lippincott; 1989:267. 16. Demetri GD, Anderson KC. Disorder of blood cell production in clinical oncology. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:628e656. 17. Haire WD. Thrombotic complications. In: Abeloff MD, Armitage JO, Lichter AS, eds. Clinical Oncology. 2nd ed. New York: Churchill Livingstone; 2000:657e689. 18. Steel GG. Introduction: the significance of radiobiology for radiotherapy. In: Steel GG, ed. Basic Clinical Radiobiology. 3rd ed. London: Arnold; 2002:1e7. 19. Van der Kogel AJ. Radiation response and tolerance of normal tissues. In: Steel GG, ed. Basic Clinical Radiobiology. 3rd ed. London: Arnold; 2002:30e41. 20. Kiyomia K, Matsuo S, Kurebe M. Differences in intracellular sites of action of Adriamycin in neoplastic and normal differentiated cells. Cancer Chemother Pharmacol. 2001;47:51e56. 21. Ferguson RJ, Ahles TA. Low neuropsychologic performance among adult cancer survivors treated with chemotherapy. Curr Neurol Neurosci Rep. 2003;3:215e222. 22. Pai VB, Nahata MC. Cardiotoxicity of chemotherapeutic agents: incidence, treatment and prevention. Drug Saf. 2000;22:283e302. 23. Bajwa SK, Bajwa SJ, Kaur J, Singh A. Anesthesia implications in emergency oncologic surgery in a case of untreated Parkinsonism. Saudi J Anaesth. 2011;5:317e319. 24. Cormier JN, Pollock RE. Principles of surgical cancer care. In: Shaw A, ed. Acute Care of the Cancer Patient. London: Taylor and Francis Group; 2005:17e30. Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004
  7. 7. 6 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6 25. Bajwa SJ, Bajwa SK, Bindra GS. The anesthetic, critical care and surgical challenges in the management of craniopharyngioma. Indian J Endocr Metab. 2011;15:123e126. 26. Bajwa SS, Bajwa SK. Implications and considerations during pheochromocytoma resection: a challenge to the anesthesiologist. Indian J Endocr Metab. 2011;15:337e344. 27. Bajwa SS. Intensive care management of critically sick diabetic patients. Indian J Endocr Metab. 2011;15:349e350. 28. Bajwa S, Bajwa SK. Anesthesia and intensive care implications for pituitary surgery: recent trends and advancements. Indian J Endocr Metab. 2011;15:224e232. 29. Bajwa SJ, Jindal R, Kaur J, Singh A. Psychiatric diseases: need for an increased awareness among the anesthesiologists. J Anaesthesiol Clin Pharmacol. 2011;27:440e446. 30. Waguespack S, Gagel RF, Maldonado M, et al. Endocrine evaluation and management of the perioperative cancer patient. In: Shaw A, ed. Acute Care of Cancer Patient. London: Taylor and Francis Group; 2005:43e67. 31. Mathes DD, Bogdonff DL. Preoperative evaluation of the cancer patient. In: Lefor AT, ed. Surgical Problems Affecting Patients with Cancer. Philadelphia: Lippincott-Rave; 1996:273e304. 32. Bajwa SJ, Gupta S, Kaur J, Singh A, Parmar SS. Reduction in the incidence of shivering with perioperative dexmedetomidine: a randomized prospective study. J Anaesthesiol Clin Pharmacol. 2012;28:86e91. 33. Botz GH, Zafirova Z. General principles of perioperative medicine. Surgical and medical perspective. In: Shaw A, Reidel B, Burton A, eds. Acute Care of Cancer Patient. London: Taylor and Francis Group; 2005:117e183. 34. Hansen E, Knuechel R, Altmeppen J, Taeger K. Blood irradiation for intraoperative autotransfusion in cancer surgery: demonstration of efficient elimination of contaminating tumor cells. Transfusion. 1999;39:608e615. 35. Henry DA, Carless PA, Moxey AJ, et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2007;17(4). CD001886. 36. Covelli V, Maffione AB, Nacci C, et al. Stress, neuropsychiatric disorders and immunological effects exerted by benzodiazepines. Immunopharmacol Immunotoxicol. 1998;20: 199e209. 37. Shavit Y, Ben-Eliyahu S, Zeidel A, Beilin B. Effects of fentanyl on natural killer cell activity and on resistance to tumour metastasis in rats. Dose and timing study. Neuroimmunomodulation. 2004; 11:255e260. 38. Bajwa SS, Kaur J, Singh A, et al. Attenuation of pressor response and dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine. Indian J Anaesth. 2012;56:123e128. 39. Bajwa SJ, Bajwa SK, Kaur J. Comparison of two drug combinations in total intravenous anesthesia: propofolketamine and propofol-fentanyl. Saudi J Anaesth. 2010;4:72e79. 40. Bar-Yosef S, Melamed R, Page GG, et al. Attenuation of the tumour-promoting effect of surgery by spinal blockade in rats. Anesthesiology. 2001;94:1066e1073. 41. Exadaktylos A, Buggy DJ, Moriarty D, et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105:660e664. 42. Biki B, Mascha E, Sessler DI, et al. Anesthetic technique for radical prostatectomy and recurrence: a retrospective analysis. Anesthesiology. 2008;109(2):180e187. 43. Bajwa SJ, Bajwa SK, Kaur J, et al. Admixture of clonidine and fentanyl to ropivacaine in epidural anesthesia for lower abdominal surgery. Anesth Essays Res. 2010;4:9e14. 44. Bajwa S, Arora V, Kaur J, Singh A, Parmar SS. Comparative evaluation of dexmedetomidine and fentanyl for epidural analgesia in lower limb orthopedic surgeries. Saudi J Anaesth. 2011;5:365e370. 45. Bajwa SJ, Bajwa SK, Kaur J, et al. Dexmedetomidine and clonidine in epidural anaesthesia: a comparative evaluation. Indian J Anaesth. 2011;55:116e121. 46. Jindal R, Bajwa SJ. Paresthesias at multiple levels: a rare neurological manifestation of epidural anesthesia. J Anaesthesiol Clin Pharmacol. 2012;28:136e137. 47. Bajwa SS, Bajwa SK, Kaur J. Care of terminally ill cancer patients: an intensivist’s dilemma. Indian J Palliat Care. 2010;16:83e89. 48. Rajagopal A, Shah HN. Anaesthesia for chronic pain patients. In: Shaw A, ed. Acute Care of Cancer Patient. London: Taylor and Francis; 2005:231e241. 49. Bajwa SS, Kulshrestha A. Critical nutritional aspects in intensive care patients. J Med Nutr Nutraceut. 2012;1:9e16. 50. Lin PP, Graham D, Hann LE, Boland PJ, Healey JH. Deep venousthrombosis after orthopedic surgery in adult cancer patients. J Surg Oncol. 1998;68:41e47. 51. Mitchell SY, Lingard EA, Kesteven P, McCaskie AW, Gerrand CH. Venous thromboembolism in patients with primary bone or soft-tissue sarcoma. J Bone Joint Surg Am. 2007;89:2433e2439. Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004
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