Anaesthesia for huge ovarian tumours

ANAESTHESIA FOR HUGE OVARIAN
TUMOUR
OBIOKONKWO, AC
[MBBS, U. PHARCOURT]
DEPARTMENT OF ANAESTHESIA
UDUTH
MAY, 2017

15 May 2017 facebook.com/imezi 2
OUTLINE

Introduction

Anatomy of the ovaries

Goals of anaesthetic management

Anaesthetic challenges

Pre-anaesthetic review

Anaesthetic considerations

Conclusion

References

Introduction

Huge ovarian tumours are becoming uncommon in
contemporary medical practice
− Earlier presentation
− Late presentations still occur

The tumours exert mechanical compressive effects on
the great vessels, solid organs, and bowel

These give rise to numerous anaesthetic concerns in
the peri-operative period, which if not watched,
could lead to disastrous complications on the table

Introduction

Such huge tumours can cause significant morbidity
and mortality owing to their size, rather than their
biology

A thorough understanding of the physiological effects
and a meticulous management are required to
avoid these complications

A multidisciplinary team may be required – plastic
surgeons, general surgeons and psychiatrists

Introduction

These tumours occur between the third and fifth
decade of life

The two most common types are serous[1,2]
and
mucinous cystadenomas

The mucinous type accounts for 15% of all ovarian
tumours[3]
of which 80% are benign

Treatment is surgical usually by laparotomy, though
successful laparoscopic surgeries have been
reported[4]

Goals of anaesthetic management

Provision of optimal operating conditions

Maintenance of stable haemodynamics

Maintenance of optimal oxygenation and ventilation
parameters

Early detection and prompt management of intra-
operative complications

Controlled but rapid emergence from anaesthesia


Patient factors

Surgical factors

Positioning

Post operative


Patient factors
– Cachectic and malnourished patient
– Suboptimal respiratory functions
– Compromised renal functions
– Anaemia and deranged liver function
parameters
– Considered to have a full stomach
– Potentially difficult intubation


Surgical factors
– Risk of sudden hypotension and respiratory
collapse
• En bloc removal versus pre-op/pre-incision
drainage
– Surgery may be associated with massive
haemorrhage and associated sequelae
– Risk of venous thrombo-embolism with
prolonged surgery
– Occurrence of re-expansion pulmonary
oedema


Re-expansion pulmonary oedema (RPE)
– Develops following rapid expansion of
chronically collapsed lungs
– Mechanism is by the increased pulmonary
vascular permeability[5,6]
– Onset is rapid, usually within one hour of lung
re-expansion
– Suggested prevention by slow re-expansion of
the lungs with spontaneous respiration[7]
– However, no standard method of prevention


Aims to
− Confirm identity and diagnosis of patient
− Establish or rule out other co-morbdities
− Ensure patient is optimised for surgery
− Review of investigations – CXR, abdominal CT, FBC,
LFT, E,U,Cr, PFT, abdominal USS, IVU, tumour markers
− Ensure availability of adequate units of blood and
blood products
− Allay anxiety and counsel on method of
anaesthesia


Aims to
− Discuss plans for elective ICU admission
− Obtain high risk consent in writing
− General anaesthesia is preferred to regional
because

Technical difficulty

High risk of epidural haematoma formation
because of dilatation of epidural venous plexus

Peripheral vasodilation, worsening the potential
haemodynamic instability following sudden
decompression of the abdomen


Pre-operative

Intra-operative

Post operative


Pre-operative
− Confirm identity of patient
− Check anaesthetic machines and monitors
− Establish peripheral and central lines
− Insert CVP catheter
− Pre-medicate as appropriate
− Position appropriately

Options: semi-recumbent, left lateral with
extention, supine with left lateral tilt


Semi-recumbent
− Prevents supine
hypotension
syndrome, RPE and
respiratory failure
− Useful if surgeons
elect to drain part of
the cystic tumour
before skin incision


Semi-recumbent
− Spontaneous
ventilation with
positive end-
expiratory pressure
support during
drainage or prior to
incision
− IPPV afterwards


Left lateral
− An extension is
provided for
abdominal support
− Preferred when
surgeons prefer to
remove the mass en
bloc
− RSI and IPPV


Supine with left lateral tilt
− Another option
− As above
− RSI and IPPV
− In all cases, the supine
position is assumed
once the tumour is
out


Pre-medication, induction and intubation
– Anxiolysis, eg, midazolam
– Anti-emetics/prokinetics, eg promethazine
– Antacids eg ranitidine
– Antisialogogues eg atropine
– Appropriate induction agents
– Appropriate muscle relaxant
– May be intubated in any of the above
mentioned positions


Intra-operative
− Maintenance
− Fluid balance and blood loss
monitoring
− Temperature monitoring and
control
− Blood pressure monitoring:
external vs invasive
− Ionotropic support as required
− Plan emergence and reversal


Post-operative
− Reversal and extubation
− ICU admission if indicated
− Close monitoring and ionotropic support if needed
− Ensure optimal body temperature
− Adequate pain relief
− NG tube drainage in cases of gaseous distension
− Prophylactic measures like heparin, early
mobilization

Problems in resource-poor settings

Challenges with obtaining adequate units for fresh
blood

Unavailability of blood products – platelet
concentrates, FFP, packed cells, etc

Occasional stock out in pharmacy

Conclusion

Huge ovarian tumours are becoming uncommon in
contemporary practice but pose numerous
anaesthetic challenges

The morbidity and mortality associated with these
tumours are related to their size, rather than their
biology

Careful anaesthetic planning is required to ensure
best results both intra- and post-operatively

A multidisciplinary approach is the best

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References
1.Vellanki VS, Sunkavalli CB. Giant ovarian serous
cystadenoma in a postmenopausal woman: a case report.
Cases Journal.2009;2:7875.
2.Valour F, Oehler E. (Images) A giant ovarian cyst. British
Medical Journal case reports. 2012;10:1136.
3.Nwobodo EI. Giant mucinous cystadenoma: case report.
Nigerian Journal of Clinical Practice. 2010;13(2):228-29.
4.Kim SK, Kim JS, Park CH, Park JW. A case of giant
ovarian cyst managed successfully through laparoscopic
surgery. Korean J Obstet Gynaecol. 2012;55(7):534-37.
5.Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC.
Reexpansion pulmonary edema. Ann Thorac Surg.1988,
45: 340-345

References
6Jackson RM, Vael CF, Alexander CB, Brannen AL, Fulmer
JD. Re-expansion pulmonary edema. A potential role for
free radicals in its pathogenesis. Ann Ref Respir Dis. 1988,
137: 1165-1171
7Kondo T, Kusunoki S, Yasuuji M, Kawamoto M, Yuge O.
Prevention of reexpansion pulmonary edema during
resection of mediastinal tumor with atelectasis. Masui
tososei. 2006, 42: 39-41.
8Shinohara H, Ishii H, Kakuama M, Fakuda K. Morbidly
obese patient with huge ovarian tomour who was intubated
while awake using airway scope in lateral decubitus
position. Masui. 2010, 59: 625-628.
9Rhona CF, Sinclair, BmedSci BM BS MRCP, Mark C Luxton,
BM BS FRCA; Rapid sequence induction. Contin Educ

Anaesthesia for huge ovarian tumours

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