Overview of oncoanesthesia

1. OVERVIEW OF
ONCOANAESTHESIA
Dr. Ravikiran HM MBBS,DNB
ADMO/CH/MLG
Department of Anaesthesiology and critical care
Central Hospital, NF Railway, Maligaon, GHY-11

3. Thanks to my alma mater

4. OUTLINE
Why oncoanesthesia?
Role of anaesthesia in cancer care.
Preoperative care
Intraoperative care
Post operative care
Cancer pain
Tumor lysis syndrome
Recent advances

5. WHYONCOANESTHESIA?
Global burden of cancer: WHO estimates 8.8million people died world wide in
2018 because of cancer.
Focusing on a range of cancer care topics to build the evidence base and identify
best practices.
Vital role that anesthesia plays in managing cancer
Strengthening anesthesia services to improve patient outcomes.

6. SPECTRUM OF CANCER PATIENTS
Childhood - Adult
Amenable to treatment – not (Curative – Palliative)
Slow growing - rapidly fatal
Head – toe
Procedure room – Major OT

7. VARIOUS SETTINGATWHICHANESTHESIACARE
PROVIDED
SCENARIOS PROCEDURES WHERE ANESTHESIA REQUIRED
Preventive Excision of genetically acquired conditions. Example: Xeroderma pigmentosa
Diagnostic Biopsy, endoscopy, laparoscopy
Staging Exploratory surgery
Curative Removal of tumor
Debulking Removal of part of tumor
Palliative Surgery to relieve discomfort, pain or organ dysfunction
Supportive Vascular access devices, Feeding tube
Others Non oncological surgery in cancer survivors

8. THE ROLE OFANAESTHESIAIN CANCER CARE
80% of patients with cancer will require anaesthesia and surgical care for treatment or
palliation.
In adults, common cancers requiring surgical care include breast, bowel, and prostate cancer.
Surgery for these types of cancers is simply not possible unless there is access to safe
anaesthesia.
In children, anaesthesia is essential for a range of diagnostic procedures, such as CT and MRI
scans and haematological procedures, as well as therapeutic procedures, such as intrathecal
chemotherapy, radiotherapy and surgery.
Anaesthesia also plays vital roles in other aspect of cancer care. Anaesthesiologists, as experts
in the management of acute and chronic pain, are likely to be involved in the management of
patients with cancer pain and those requiring palliative care

9. TEAMWORK
Anaesthesiologists are at the forefront of
clinical teams.
Multidisciplinary teams improve patient
experience, safety, productivity, and enhance
the working lives of all involved.
Teamwork requires skills that include
leadership, communication, mutual monitoring,
and giving and receiving feedback.
Alerts complications, resource utilization,
avoids delay.

10. PREOPERATIVEASSESSMENT
Timing of surgery
Etiology
5M
Assessment
Optimisation and Prehabilitation
Multidisciplinary Team approach
ERAS protocols
DVT prophylaxis
Consent
DNR
Advance directives

11. ACC andAHAdefinition
Emergency procedure – life/limb is threatened if not in the OR within 6 hours, i.e. little to no
time for clinical evaluation
Urgent procedure – limited time for clinical evaluation, life/limb is threatened if not in OR
between 6 and 24 hours
Time-sensitive procedure – a delay > 1-6 weeks would negatively affect outcome. Most
oncology cases falls in this group.
Elective procedure – could be delayed up to 1 year without risking outcome
Note: Onco-surgery can be any of the above.

12. PERFORMANCE STATUS
In anesthesia we use METS. In oncology ECOG/Karnofsky correlate with response to
chemotherapy, chemotherapy tolerability, survival, and quality of life of cancer patients.
However, these scales are subjective. Use of objective E-gadgets.

13. ETIOLOGYIMPLICATIONS
Genetic: It may be a part of syndrome. Ex: Xeroderma, Neurofibramatosis, Obesity
Environmental: other systemic involvement. Ex: smoking
Infective: Risk of health care provider exposure and systemic illness. Ex: HIV, HPV,HBV

14. HISTOPATHOLOGYIMPLICATIONS
Reviewing HPE report will help better planning
Ex: Thyroid FNAC:
 Medullary ca: it can be part of syndrome, retrosternal extension, LN spread
 Follicular ca: hyperthyroid, metastasis to brain, bone, lung
 Papillary ca: LN spread (need LN dissection-prolonged surgery)
 Lymphoma: Radiotherapy history
 Anaplastic: surrounding organ infiltration

15. 5M of Malignancy
1. Mass effect
2. Metastasis effect
3. Medication effect
4. Metabolic effect
5. Mental effect

16. MASS EFFECT
Compression and infiltration of surrounding structure.
Ex: Thyroid mass compressing/infiltrating trachea, tense ovarian tumor
compressing abdominal viscera and reducing diaphragm excursion
Assessment: Clinical and radiology

17. METASTASIS EFFECT
Metastasis to vital organs.
Ex: Brain mets, adrenal mets, Hepatic mets, Lung mets
Assessment: Clinical and radiology

18. MEDICATION EFFECT
Adverse effect of Chemotherapy, Radiotherapy, Immunotherapy, Alternative
medicine
Assessment: Clinical, blood investigation and radiology

19. CHEMOTHERAPY
Unique: vocal cord paralysis with vinca
alkaloids.
Evaluation:
CBC
Serum electrolyte
RFT
LFT
DLCO
ECG and 2DEcho
MRI brain
NCS

20. RADIOTHERAPY
If neck radiation:
 Edema, Frail mucosa and fibrosis can cause
difficult intubation
 Carotid body/sinus receptor insensitivity can
lead to altered hemodynamic response to
intubation
 Thyroid dysfunction
 Difficult surgery
If cardiac area: CAD, Conduction
abnormality, Cardiomyopathy,
Pericarditis
Evaluation: organ specific
investigations

21. IMMUNOTHERAPY

23. METABOLIC EFFECT
Metabolic changes in body
Malnutrition, Cachexia, Secreting tumors, Tumor lysis syndrome, Chemotherapy
side effect
Assessment: Clinical and blood investigation

24. MALNUTRITION, CACHEXIA

28. IMMUNOSUPPRESSION
Cause:
 Cancer per se
 CT
 RT
Adrenal suppression: organ transplant, steroid therapy
Implications: Strict asepsis, Stress dose

29. MENTALEFFECT
Psychological stress
Depression, Damocles syndrome, Multiple hospitalisation
Assessment: Clinical and onco-psychiatric consultation

30. DVT PROPHYLAXIS
Khorana score and risk categories

31. BLEEDING RISK

32. RISK OFBLEEDING V/S DVT

33. DIFFICULTVASCULARACCESS
Cancer patient have difficult IV:
thromboplebhitis, irritant chemodrug,
multiple times need of vascular
access, steroid therapy, dehydrated,
fragile
Anesthetist are experts among
doctors for securing vascular access
Long term: Central line, PICC,
Hickman Catheter, Implantable
Chemoport

34. INTRAOPERATIVE
Prolonged surgery
Blood transfusion vs risk of immune modulation
GA vs risk of immune modulation

35. ANESTHESIADRUG – TUMOR RECURRENCE

36. SURGERY– TUMOR RECURRENCE

37. GAV/S RAIN CANCER SURGERY
GA RA
Advantages:
Time: Can be used for short as well
long duration surgery
Advantages:
Positive effect on cancer prognosis
LA inhibit tumor growth
Reduce opioid consumption
Reduces acute pain, chronic pain, PONV, and pulmonary
complications.
RA can reduce length of stay and improve operating
department throughput.
Disadvantages:
?Risk of cancer recurrence due to GA
immunomodulation
Opioid reduce cell mediated immunity
Disadvantages:
Neuraxial technique risk of hemodynamic changes
Anxious patients
Although RA confers short-term functional benefits,
these are generally not sustained.

38. DRUG INTERACTIONS
CHEMO DRUG INTRAOP DRUG EFFECT
Methotrexate Nitrous oxide Myelosuppresion
Azathioprine NDMR Need more NDMR dose
Cyclophosphamide Scoline Scoline action prolonged
Corticosteroids NSAIDS Potentiate risk of GI bleed
Cisplatin Frusemide Ototoxicity
Imatanib Paracetamol Reduced metabolism of PCT
Aprepitant Dexamethasone Dexamethasone dose reduction
Methotrexate NSAID Thrompbocytopenia, MTX toxicity

39. BLOOD TRANSFUSION
PROS CONS
Anemia is common Immunomodulations
Malnourished Cancer recurrence
High bleeding risk Infection
Associated comorbidity: IHD, CKD Host-Graft reaction

40. POST OPERATIVE
DVT
PONV
ICU stay
Rehabilitation
Nutrition: TPN, refeeding syndrome

41. PONV
Cancer patient are more risk of PONV specially post Chemo. Apprepitant induces and inhibit
CYP enzyme, Dexamethasone dose reduction recommended.

42. POST-OPDVT PROPHYLAXIS

43. CANCER PAIN MANAGEMENT
Components: Sensory, affective,
psychological
Causes: Tumor progression, indirect
metabolic effect, consequence of treatment,
unrelated
Primary focus: treatment of malignancy
WHO analgesic ladder
Low pain threshold, periop management of
cancer pain patients

44. TUMOR LYSIS SYNDROME
It’s a medical emergency
Most commonly with Acute Leukemia (high proliferative and large tumor burden)
Caution giving steroids
Clinically: AKI, Seizure, Arrhythmia, Tetany
Investigations: Cairo-Bishop criteria
• ↑K+, lactate, PO4,Uric acid
• ↓ Ca
Treatment: Hydration, Rasburicase, Allopurinol, Monitor electrolytes

45. RECENTADVANCES
Hyperthermic chemotherapy
Robotics
Cath lab-Interventional procedures
Pulmonary interventional procedure
NOTES, TORS
NORA: Radiotherapy suit
Steriotactic procedure
Oncoplasty, Transplant
Onco-critical care

46. THANKYOU
CANCER