Oncoanaesthesia involves the anesthetic management of patients undergoing cancer-related procedures. It is a vital part of cancer care as 80% of cancer patients require anesthesia. Anesthesiologists play key roles in preoperative optimization, intraoperative management considering implications of cancer and its treatments, and postoperative care including management of complications like pain, DVT and PONV. Special considerations include impacts of cancer type and stage, prior treatments, and multidisciplinary teamwork to improve outcomes.
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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.
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
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
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
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
41. PONV
Cancer patient are more risk of PONV specially post Chemo. Apprepitant induces and inhibit
CYP enzyme, Dexamethasone dose reduction recommended.