Anaesthesia for Cancer Patients Mujeebullah Rauf Arain and Donal J

Anaesthesia for cancer patients Mujeebullah Rauf Arain and Donal J. Buggy Purpose of review Introduction Cancer is beginning to outpace cardiovascular disease as Cancer is the second leading cause of death in the devel- the primary cause of death in the developed world. A oped world, accounting in 2004 for over half a million majority of cancer patients will require anaesthesia either for deaths. Cancers at four organ sites – lung/bronchus, colo- primary debulking tumour removal or to treat an adverse rectal, breast and prostate – accounted for 56% of all consequence of the malignant process or its treatment. cancer cases and 53% of all cancer deaths [1]. Approxim- Therefore we outline here the pathophysiology of cancer, ately half of patients diagnosed with cancer will develop generalized metastatic disease and systemic chemotherapy metastatic disease. Over 70% of all cancer patients develop and radiotherapy on major organ systems. The anaesthetic symptoms from either their primary or metastatic disease considerations for optimum perioperative management of [2]. The overall metastatic burden and the number and cancer patients are discussed, and the possibility of location of the sites involved by disease influence prog- anaesthetic technique at primary cancer surgery affecting nosis. There is an increasing surgical intervention rate long-term cancer outcome is mentioned. in cancer patients, both for primary tumour excision Recent findings and emergency intervention for intercurrent illness. Cancer and its therapy can adversely affect every major Coupled with the increased use of chemotherapeutic organ system with profound implications for perioperative agents over the past decade, cancer patients requiring management. Retrospective analysis suggests an surgery present particular challenges for the anaesthe- association between regional anaesthetic techniques at tist [2]. This review outlines acute perioperative care for primary cancer surgery and reduced incidence of cancer patients. Early research reports suggest a possible metastatic disease. association between perioperative anaesthetic technique Summary and cancer outcome. Chronic pain management of cancer Optimum perioperative patient care requires individual patients, and acute cancer pain management outside the assessment of the impact of cancer and its treatment on the context of the postoperative period, is beyond the scope of functional reserve of all major organ systems. The potential this work. of anaesthetic technique at cancer surgery to influence long-term cancer outcome merits investigation. Systemic effects of cancer and metastasis Keywords Pain is one of the most common and feared symptoms cancer, cancer treatment, chemotherapy, general associated with cancer. It occurs in 25% of patients with anaesthesia, radiotherapy, regional anaesthesia newly diagnosed malignancies, and in 75% of those with advanced disease [3]. Curr Opin Anaesthesiol 20:247–253. ß 2007 Lippincott Williams & Wilkins. Measurable psychological distress and depression affects Division of Anaesthesia, Intensive Care and Pain Medicine, Mater Misericordiae up to 70% of all oncology patients. Interest has increased University Hospital, Dublin, Ireland intherolethatpsychologicaldistressmayplayin Correspondence to Dr Donal J. Buggy, Consultant in Anaesthesia, MD, MSc, DipMedEId, FRCPI, FCARCSI, FRCA, Division of Anaesthesia, Intensive Care and complicating the presentation, treatment and prognosis Pain Medicine, Mater Misericordiae University Hospital and National Cancer of patients with cancer [4]. Screening Service Eccles Unit, Dublin 7, Ireland Tel: +353 1 8301122/8302281; fax: +353 1 8300080; e-mail: [email protected] Approximately half of all cancer patients develop Current Opinion in Anaesthesiology 2007, 20:247–253 cachexia [5], characterized by anorexia, weight loss, weak- ness, poor performance and impaired immune function [6]. ß 2007 Lippincott Williams & Wilkins 0952-7907 Adequate vascular access is required for effective administration of chemotherapeutic agents, blood products, nutritional support and the multiple blood tests needed for monitoring cancer patients [7]. Central line insertion may be difficult in patients with cancer because of coagulopathy, multiple previous attempts in the same vessels, or difficulty in placing patients supine where there is respiratory distress. 247 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 248 Anaesthesia and medical disease Cardiac side effects of cancer therapy provide a consider- it occurs in approximately 10% of all cancer patients [15]. able challenge to the clinician. Arrhythmias, radiation- It is most commonly seen in squamous cell carcinoma induced myocardial ischemia, congestive heart failure, of the bronchus in the absence of bony metastasis, anthracycline and radiation-induced cardiomyopathy, suggesting a humoral factor in its aetiology. Breast cancer peripheral vascular disease and pericardial disease can causes excessive calcium mobilization from bone in the all be caused by different cancer therapies [8]. presence of multiple osseous metastasis, and multiple myeloma is associated with local bone destruction and It is estimated that 5–10% of patients taking chemother- abnormal renal function [15]. apy may experience an adverse pulmonary reaction. The clinical syndrome of radiation pneumonitis develops Hyponatraemia (serum sodium >145 mmol/l) results in 5–20% of all irradiated patients. Factors that increase from an impaired ability to excrete a water load, due the incidence of lung toxicity include concomitant to inability to produce dilute urine. Arginine vasopressin administration of oxygen, radiation therapy, IV route of activity is increased in patients with hyponatraemia of administration, going above an established cumulative malignancy [16]. Syndrome of inappropriate antidiuretic threshold dose, pre-existing respiratory morbidity and hormone (SIADH) is the most common cause of hypo- advanced age [9]. natraemia among cancer patients. Neoplasms associated with SIADH are small cell carcinoma of lung, and carci- Mechanisms of renal failure include pre-renal failure noma of the pancreas, bladder, prostate, breast and colon. secondary to inadequate renal perfusion from fever- induced dehydration or cardiac failure. Intrinsic renal Tumour lysis syndrome (TLS) is a spectrum of metabolic failure in the cancer setting may result from generalized derangement usually associated with the cytotoxic sepsis syndrome or nephrotoxic therapy, including anti- therapy of malignancy. It is characterized by numerous biotics. Urinary obstruction commonly occurs with locally metabolic abnormalities (including hyperuricemia, advanced pelvic cancers, for example, prostate and cer- hyperphosphatemia, hypocalcaemia, hyperkalaemia and vical cancers [10]. uraemia) and frequently leads to acute renal failure. Malignancies associated with TLS are acute and chronic Neutropenia is common in cancer patients either because lymphoid and myeloid leukaemia, small cell carcinoma of the malignant process interferes with bone marrow func- the lung, and testicular and breast cancers [17]. tion or because chemotherapeutic regimens administered to treat the disease cause myelosuppression. Since the Haematological problems neutrophil is an important host defence against many Anaemia tends to increase in severity as the stage of the pathogens, neutropenic patients are at increased risk of disease progresses. Malignancy-associated anaemia is developing opportunistic infection. The frequency of designated as an anaemia of chronic disease. Serum infectious complications is related to the degree and erythropoietin levels are inappropriately low for a given duration of neutropenia [11]. level of anaemia in patients with cancer. It is possible that erythropoietin-producing cells are either directly sup- Infection in hospitalized oncology patients poses a pressed by the malignancy itself or that these cells are serious challenge and may lead to unfavourable impact functionally impaired by chemotherapy or radiation on successful cancer treatment outcomes. In addition, therapy [18]. nosocomial infections are well recognized predictors of prolonged hospital stay and increased cost [12]. Leukopenia is associated with cytotoxic treatment in 20–50% of patients with solid tumours. The probability More than 75% of patients receiving combination che- of clinical infection is proportional to its severity and motherapy are affected [13]. The chemoreceptor trigger duration [19]. zone, located in the area postrema at the ventral aspect of the fourth ventricle, can be stimulated by drugs including Thrombocytopenia in cancer patients is usually attribu- opiates, anaesthetic agents, and cancer chemotherapy. table to chemotherapy and radiation therapy. However, Metabolic abnormalities, for example, uraemia, hypoxia thrombocytopenia may also be due to splenic sequestration and ketoacidosis, may also cause nausea and vomiting. in patients in whom splenomegaly is part of the primary neoplastic process [20]. Acute abdomen or bowel obstruction, bleeding and fistula formation can present as emergent surgical problems in The incidence of thrombosis is 2–10% of all patients with cancer patients [14]. cancer. Most thrombotic complications occur postopera- tively. Thrombosis can be the first symptom of an Hypercalcaemia (serum calcium >2.7 mmol/l) is the occult malignancy. Patients with adenocarcinoma are at major metabolic abnormality seen in malignant

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