Episode #115 Keeping Patients with Cancer Safe During Anesthesia Care

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are getting close to the next Newsletter release in October, but we still have time to talk about more articles from the June 2022 APSF Newsletter. Do you take care of patients undergoing surgery for cancer treatment? This week, we are going to be talking about how to keep patients with cancer safe during anesthesia care and pain management.

Before we dive into the episode today, we’d like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Preferred Physicians Medical Risk Retention Group – we wouldn’t be able to do all that we do without you!.”

Our featured article today is “Anesthesia Pain and Safety Considerations in Cancer Patients” by Dylan Irvine and Jeffrey Huang. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well. Before we get into the article today, we are going to hear from one of the authors. Let’s take a listen now.

[Jeffrey Huang Clips] My name is Jeffrey Huang. I am an anesthesiologist at Moffitt cancer center in Tampa, Florida. My co-author is Dylan Irvine who is a medical student at Nova Southeastern University.

[Bechtel] To kick off the show today, I asked Huang, why he wrote this article? This is what he had to say.

[Huang Clips] “There will be approximately 1.9 million cancer case diagnosis, equivalent of about 5,00 new cases a day. Nearly 40% of people in the US will be diagnosed with cancer at some point in their lifetime. Approximately 60% of the cancer patients will undergo some type of surgery to treat their cancer.  Cancer surgery is a common procedure. Anesthesia providers deliver 1-4 anesthesia services for each cancer patient Because of new cancer treatment, cancer deadly?? had dropped approximately 30%. These new drugs and surgical techniques create new challenges for anesthesia providers. Therefore, we wrote this article to help anesthesia providers understand the anesthesia safety for cancer patients.”

Thank you so much to Huang for helping to kick off the show today. And now, let’s discuss the article with the focus on onco-anesthesia. Anesthesia professionals often need to take care of cancer patients for surgery and pain management and be prepared to keep them safe. Additional considerations include cancer-related or cancer treatment-related co-morbidities and the interactions and side effects of antineoplastic therapies with the anesthetic plan. Today, we are going to talk about the perioperative considerations for patients with cancer. Let’s start before we even set foot into the operating theatre with the preoperative considerations.

Here we are in the pre-operative holding area or in the preop anesthesia clinic. Your history reveals that the patient has cancer and has received chemotherapy for treatment. It is important to evaluate the following:

• What chemotherapy agent or agents has the patient received
• Treatment details including timing, dose, and duration
• Side effects or complications from the treatment
• Current cardiac and pulmonary function and any changes because of the therapy

Keep in mind that many chemotherapy agents can affect the heart and lungs. Busulfan, cisplatin, cyclophosphamide, doxorubicin, and 5-fluorouracil are all associated with cardiac toxicity. Patients who receive these medications may need a cardiology consultation prior to elective surgery and considerations for obtaining an echocardiogram to evaluate heart function. Patients who present for emergency surgery and have received these medications will need to be evaluated at bedside to assess functional status and considerations for a bedside point of care ultrasound or PoCUS to assess volume status, cardiac function, and respiratory function. Be on the lookout for patients who receive anthracycline chemotherapy. One of the associated risks includes chemotherapy-induced cardiotoxicity which may present with acute intraoperative left ventricular failure that does not respond to treatment with beta-adrenergic receptor agonists, thus treatment with phosphodiesterase inhibitors may be required. There is an increased risk of cardiotoxicity from anthracycline chemotherapy with increasing total dose, high-dose mediastinum radiation therapy, concurrent cyclophosphamide therapy, extremes of age, history of ischemic heart disease, hypertension, valvular heart disease, and liver disease.

Methotrexate, bleomycin, busulfan, cyclophosphamide, cytarabine, and carmustine are all associated with pulmonary toxicity including dose-dependent interstitial pneumonitis, and pulmonary veno-occlusive disease. Patients may describe dry cough and breathlessness with exercise with minimal changes on chest x-ray. These patients are at increased for requiring postoperative mechanical ventilation. Be on the lookout for patients who have received bleomycin in the past since these patients may develop bleomycin-induced lung injury when exposed to high concentrations of inspired oxygen. Intraoperative and postoperative management for patients treated with bleomycin includes reduced oxygen concentrations if possible to decrease the risk for respiratory complications.

Now, it’s time to move into the operating room to discuss the intraoperative considerations. First up, lets discuss temperature management and avoidance of hypothermia. The majority of surgical patients, between 50-70%, develop intraoperative hypothermia with core body temperature less than 36 degrees Celsius. Risk factors include surgical duration, age, and baseline body temperature. Cancer patients are at risk of intraoperative hypothermia. Prevention of intraoperative hypothermia is important because it puts patients at risk for the following:

• longer surgical recovery time for general anesthesia
• arrhythmias
• coagulopathies
• longer duration of intubation
• increased postoperative length of hospitalization

In addition, hypothermia during cancer resection has been associated with negative effects on postoperative immune function and cytokine levels, especially for patients with gastrointestinal cancer. Other important considerations include increased postoperative complications and higher rates of pathologic state and higher recurrence rate within 12 months for cancer patients with intraoperative hypothermia.  Keeping patient warm and safe in the OR includes intraoperative warming for cases longer than 60 minutes and warmed intraoperative fluids and transfusions. Postoperative management includes continued temperature monitoring, thermal insulation, and treatment for shivering which may include meperidine, clonidine, or dexmedetomidine. The authors remind us that dexmedetomidine has additional side effects of sedation, hypotension, dry mouth, and bradycardia.

Another intraoperative considerations is careful positioning with the goal to prevent peripheral nerve injuries. Patient undergoing tumor resection are at risk for nerve injuries from compression and impingement of the nerve by the tumor as well as from inappropriate patient positioning. The most common peripheral nerve injuries during surgery include ulnar, brachial plexus, and common peroneal nerves. Cancer resection surgeries may be of longer duration too and it is vital that anesthesia professionals are involved in the initial positioning and check on pressure points and positioning throughout the surgery as well. Careful positioning may help to prevent peripheral nerve injuries with padded arm boards, padding around the elbow, and padding to limit pressure on the fibular head.

We are taking a quick time out from the article to review one of the APSF Patient Safety Priorities, Clinical Deterioration, which includes Preventing, detecting, determining pathogenesis, and mitigating clinical deterioration in the perioperative period. Additional considerations for clinical deterioration are perioperative early warning systems, appropriate monitoring which may require monitoring continuously on the hospital floor postoperatively, for opioid-induced impaired ventilation, and for early sepsis. It is important to be able to recognize and respond appropriately to the decompensating patient during the perioperative period.

The authors discuss appropriate intraoperative monitoring for cancer patients and this is aligned with the APSF priority of clinical deterioration. Careful monitoring of high risk patients with complex medical histories, comorbidities, age, body mass index, ASA status, frailty, poor mobility, presence of terminal illness, and surgery type and complexity is vital so that anesthesia professionals can detect shock states and intervene quickly and appropriately to keep patients safe. Monitoring of continuous electrocardiography, noninvasive blood pressure, end tidal carbon dioxide monitoring, and pulse oximetry may be adequate for hemodynamically stable patients. You may need to consider intra-arterial blood pressure monitoring with arterial blood gas analysis for patients who are hemodynamically unstable or have significant co-morbidities. Pocus may be helpful to evaluate volume status, cardiac function, lung status, and respiratory function especially in the setting of hypovolemia and intra-abdominal or intrathoracic bleeding.

We made it out of the OR and into the postoperative period. Pain management is a complex and important consideration for cancer patients who may have existing pain due to malignancy as well as significant postoperative pain. This is a big threat to patient safety since persistent postsurgical severe pain may occur in 5-10% of cancer patients from trauma and the resultant nerve injury followed by central sensitization. Patients may not receive adequate pain relief due to the following:

• Political barriers leading to decreased availability of opioids
• Prescriber-related barriers related to poor understanding of pain assessment and management in cancer patients, apprehension in opioid prescribing, and complications of respiratory depression or excessive sedation
• And Patient fears of addiction or side effects as well as concerns that the pain management means that they are approaching the final stages of life.

Let’s review options for pharmacologic management of cancer pain. For mild cancer pain, non-opioid analgesia including paracetamol and non-steroidal anti0inflammatory drugs may be used. For patients with moderate and severe cancer pain, less potent and more potent opioid may be added to the treatment.

Cancer patients who are on long-term and high-dose opioids may have increased opioid requirements. An appropriate pain management treatment plan may include some of the following multi-modal analgesia options.

• Paracetamol
• NSAIDS
• Alpha-2-delta subunit modulators such as gabapentin
• Intravenous ketamine infusion which has been show to decrease postop pain medication requirement and pain intensity
• Intravenous lidocaine infusions have been studies as well, but the benefits of reduced pain have not been confirmed.
• Local anesthetic infusion with long-term catheter placement may decrease development of chronic pain post-op.
• Peripheral nerve blocks and fascial plane blocks which have the advantage over neuraxial techniques and general anesthesia of less systemic side effects such as sympathetic blockade, hypotension, and urinary retention and improved postoperative pain control.

An important anesthetic consideration for cancer patients is psychological distress, especially depression. This is not something that anesthesia professionals often think about, but it is related to patient outcomes. Keeping cancer patients during anesthesia care requires making sure that patients have appropriate referrals and access to psychological support and counseling. This is supported in the literature as well. Check out the 2016 study by Park and colleagues called, “Risk factors for postoperative anxiety and depression after surgical treatment for cancer.” I will include a link in the show notes as well. The authors evaluated patients undergoing curative surgical resection for primary lung cancer and found that thoracotomy, postop dyspnea, severe pain, and diabetes were risk factors for the development of postop anxiety and depression. Psychological evaluation and management should not just happen during the postoperative phase, but is important at every stage of cancer treatment starting at the initial management and supporting patients over time. Another study looked at patients with breast cancer and found that there was an increase incidence of depression for up to three years following mastectomy. Going forward, improved psychological counseling for cancer patients during the postoperative time period may help improve morbidity and mortality.

We made it to the end of the article. Don’t forget to include these important considerations for cancer patients as part of your anesthetic plan. Before we wrap up for today, we’re going to hear from Huang again. I asked him, what do you envision for the future? Let’s take a listen to what he had to say.

[Huang] “Individualizing medicine, immunotherapy, and new chemotherapy have showed exciting result in cancer treatment. These new treatments have made us closer to curing cancer. However, we still don’t know how these new treatments affect anesthesia care and patient safety. Therefore, more research are needed.”

[Bechtel] If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Here’s a spoiler alert for next week. We are going to be talking about and hear from Elizabeth Rebello, an APSF board member, and Dominic Carollo from Oschsner Health, who were recently interviewed for a Chime Opioid Action Center Podcast. The focus for the podcast is on why the OR and Procedural areas have unique challenges for monitoring for potential drug diversion as well as their frontline experiences, how their organizations have acted to increase awareness and successfully used technology and processes to help prevent and be able to detect drug diversion. If you can’t wait until next week, then we hope that you will check out the whole podcast. I will include a link in the show notes as well.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation