Join us for a compelling presentation on 'Anesthesia for Torsion Testis in the Context of Tumor Lysis.' Delve into the delicate balance of anesthetic management for patients facing the dual challenge of testicular torsion and tumor lysis syndrome.

1. Anesthesia for Torsion testis
patient in tumor lysis syndrome-
A CASE PRESENTATION
DR NAYANA KULKARNI
HCG MANAVATA CANCER CENTER NASIK.

2. CASE IN NUTSHELL
• 21 YR MALE PATIENT,
HEIGHT 150 CM WEIGHT 34
KG, BMI- 14.5
• C/O BREATHLESSNESS AND
SEVERE DEABILITY AND
LEFT SCROTAL SWELLING
WITH severe PAIN.
• WAS INVESTIGATED FOR 1
MONTH {OUTSIDE} AND no
treatment or biopsy done for
diagnosis
• A CT SCAN SHOWED
MULTIPLE METASTATIC
LESIONS IN LUNGS AND
LIVER, ABDOMEN
ENCASING AORTA, IVC
RENAL VEINS AND
MEDIASTINUM.
• ALSO EXTENDING IN
LEFT NECK CAUSING LEFT
BRACHEO-CEPHALIC VEIN
COMPRESSION AND
PARTIAL LEFT APICAL
LUNG COLLAPSE.
• DIAGNOSED TO HAVE
TORSION OF LEFT TESTIS.
• WAS IN TUMOR LYSIS-
HIGH LDH,BETA HCG AND
AFP
• HIGH URIC ACID,
POTASSIUM AND
HYPOCALCEMIA WITH
ARRHYTHMIA [ sinus
tachycardia]

3. INVESTIGATIONS
S.
NO
INVESTIGATION VALUE
[28/11/23]
VALUE
[30/11/23]
1 Hb 8.9 8.3
2 WBC 14100 12220
3 PLATELET 51000
4 URIC ACID 10.0
5 CALCIUM 7.4
6 PHOSPHORUS 5.5 3.5
7 BILIRUBIN
T[IND/DIRECT]
3.5 [2.3/1.2]
8 CREATININE 1.5 1.0
9 SODIUM 129.8 133
10 POTASSIUM 5.8 4.04
11 CHLORIDES 99 103
12 PT INR 1.3 1.1
13 SGPT 224
14 SGOT 806.2
15 ALK PHOSPHATASE 409.7
16 BUL 17.9 108
SR.NO INV VALUE
[29/11/23]
17 TOTAL PROTEINS 5.8
18 ALBUMIN 2.8
19 GLOBULIN 3.0
20 LDH [U/L] 13676[N-MAX
450]
21 BETA HCG [ mIU/ml] 17700 [n- 0-3]
22 ALFA FETO PROTEIN
[IU/ML]
1790 [n- 0-10]
S no investigati
on
Value
[25/11/23]
1 Na 131
2 K 4.2
3 SGPT 96
4 SGOT 100
5 Hb 10.5
6 PLATELET 1.5 LACS
7 WBC 4200

6. ANESTHETIC CONSIDERATIONS
• Severe Cachexia- BMI less than 19.5.
• Cough
• Fever [99.5F]
• Hypoalbuminemia
• Jaundice.
• Hyperphosphatemia
• Hypocalcemia
• Glucose insulin drip for treating hyperkalemia
[ 25% increase from baseline]
• Tumor lysis- spontaneous without treatment initiation.

7. • Bed ridden- DVT risk , but- as platelets low, cannot start
pharmacological dvt prophylaxis.
• Torsion of testis and severe pain – emergency case.
• Regional blocks- difficult as swelling and pain in inguinal region.
• Thrombophlebitis, left arm swelling , difficult venous access.
• Lung mets - GA is difficult as patient may have delayed recovery,
drug interactions and there are reports of tumor lysis under GA
too.
• Disoriented and apathetic, dehydrated, needs stabilization before
intervention in limited period.
• Needs anesthesia plan which will allow good analgesia , good
surgical field and rapid recovery postop without residual
effects.
• Mild sedation and oxygen support.

8. Anesthesia plan
• As thrombocytopenia [count
48,000], SDP given and
• Repeat Pl count was 60,000.
• Then, patient taken for surgery.
• Hydrated and vitals monitored-
preoperative optimization done.
• Unilateral spinal anesthesia
decided.
• Left lateral position- [left testis
torsion]
• pt couldn’t lie supine due to
dyspnoea so 20 degree head up and
lateral decubitus position given
• O2 by mask.
• Preload 200 ml of fluid.(OVER 10 MIN)
• 1.0ml of 0.5% bupivacaine [heavy] with
27 Whitacre spinal needle.
• Drug injected over 3 min.
• Lateral position kept for 12 min, action at T9
level- checked.
• Surgery started, went over 70 min.
• Intraoperative mild sedation 1mg
midazolam and antiemetic given
[ ondansetron 4mg]

10. TREATING TUMOR LYSIS SYNDROME PREOP GUIDELINES
• Volume Expansion- Volume expansion is accomplished by
crystalloids solutions, which increase the urine output and thus
the phosphate, potassium, and uric acid excretion.
• Apart from this effect, salt delivery to the distal tubules
increases potassium secretion and lowers kalemia.
• Decreasing the urinary calcium x phosphate product also
prevents the precipitation of the crystals.
• Diuretics - Diuretics are not routinely recommended because
they induce volume depletion, thus compromising the renal
hemodynamics even more.
• Alkalosis- alkalinization decreases calcium phosphate solubility
and favors crystals precipitation in renal tubules and soft tissues.

11. • Alkalosis increases the amount of
calcium that is bound to albumin and
favors arrhythmia and tetany. Therefore,
urine alkalinization is not recommended
as it may even be dangerous.
• Treating Hyperphosphatemia - The
main therapeutic measure is the increase
in phosphaturia by volume expansion
with isotonic solutions.

12. • Calcium Supplementation
• Calcium is not routinely recommended, because it
increases the precipitation of calcium in the soft tissues
and it aggravates AKI.
• Calcium administration is recommended only in certain
conditions: severe and symptomatic hypocalcemia
(tetany, Chvostek sign,muscular fasciculation,
bronchospasm, laryngospasm, seizures), changes of the
electrocardiogram, and arrhythmia.
• In these cases, treatment is administered in order to
alleviate the symptoms and not to normalize the
calcemia.

13. • Treating Hyperkalemia
• Hyperkalemia must be promptly treated because it
can induce life threatening arrhythmias.
• When potassium value increases with more than
25% compared to baseline value or when kalemia
reaches 6 mmol/L, cardiac monitoring is
recommended, altogether with the standard
treatment: beta-adrenergic agonists (albuterol),
glucose-insulin solution, short calcium gluconate
infusion for myocardial protection, loop diuretics,
and potassium binding resins in order to increase
digestive loss.

16. • Tumor lysis syndrome (TLS) is the result of a series of events leading to the rapid
death of a high number of malignant cells.
• Lysis of these cells leads to the release of intracellular ions and metabolic
byproducts into the bloodstream, resulting in
• hyperuricemia,
• hyperkalemia,
• hyperphosphatemia, and
• hypocalcemia.
• All these disturbances may cause serious complications such as
• AKI,
• cardiac arrhythmias, seizures, and
• even death

17. TLS is an oncological emergency with high morbidity and
mortality, especially if the diagnosis is delayed and
treatment measures are not instituted promptly
It may occur either spontaneously, or after antineoplastic
therapy such as
• conventional chemotherapy,
• corticosteroids,
• molecular-targeted therapy,
• immunotherapy,
• and even after radiotherapy and
• Chemoembolization

18. 20. Cairo, M.S.; Bishop, M. Tumour Lysis Syndrome: New Therapeutic Strategies and Classification. Br. J. Haematol.
2004, 127, 3–11.
[CrossRef]

22. Galoian, K.;Qureshi,A.; Wideroff,G.;Temple,H.T.RestorationofDesmosomalJunction ProteinExpressionand
InhibitionofH3K9-SpecificHistoneDemethylaseActivity byCytostatic Proline-RichPolypeptide-1Leadsto
Suppression ofTumorigenicPotentialin HumanChondrosarcomaCells.Mol.Clin.Oncol.2015, 3,171–178. [CrossRef]

26. Patience is a virtue.