The Cancer Patient and Anesthesia

1
The Cancer Patient and Anesthesia

• Jan Friedman
• Caroline Kigotho

2
Objectives

• Discuss the anesthetic management of the cancer
  patient.
• Discuss anatomy and physiology of cancer.
• Discuss the pathophysiology of cancer.
• Discuss pharmacological management of the cancer
  patient undergoing anesthesia.
• Discuss the management of complications for the
  cancer patient.
• Utilize a case presentation format to synthesize
  the anesthetic management for cancer patients.
• Review questions relating to the anesthetic
  management of cancer patient to assess SRNA
  learning.

3
CANCER

• Second leading cause of death in US.
• Develops in 1 of 3 Americans.
• One of every 5 cancer victims die from the
  effects of their disease.
• Number of deaths increasing with growing elderly
  population.

4
Physiology

• Critical gene related to cancer in humans is the
  tumor suppressor p53.
• P53 gene is essential for cell viability,
  monitors damage to DNA.
• Inactivation of p53 is an early step in the
  development of many types of cancer.
• Genes are involved in carcinogenesis by virtue of
  inherited traits that predispose to cancer
  (altered metabolism of potentially carcinogenic
  components, decreased level of immune system
  function).
• Stimulation of oncogene formation by carcinogens
  (tobacco (1), alcohol, sunlight) Responsible for
  80 of US cancers.

5
Physiology

• Cancer cells invade the hosts immune system that
  destroys tumor cells.
• Mutant cells stimulate the hosts immune system
  to form antibodies.
• Some cancer cells are metastatic.
• Increased incidence of cancer in immunosuppressed
  patients such as those with AIDS and those
  receiving organ transplants.

6
Diagnosis

• Cancer becomes evident when the tumor cells
  compromise function of vital organs.
• Initial diagnosis by aspiration cytology or
  biopsy.
• A common staging system for solid tumors is the
  TNM system based on size (T), lymphnode
  involvement (N), distant metastasis (M).
• Patients are then grouped into stages from best
  prognosis (stage1) to poorest prognosis (stage 3
  or 4).

7
TreatmentChemo, Radiation , Surgery

• Chemotherapy may produces significant side
  effects that have important implications for the
  management of anesthesia.

• Surgery for initial diagnosis (biopsy) definitive
  treatment, pallative care, and TX of pain

• Surgery

• Chemo

8
Complications

• Renal Toxicity
• Hepatic Toxicity
• CNS toxicity
• PNS toxicity
• ANS toxicity
• Stomatitis
• Plasma Cholinesterase Inhibition
• Coagulation defects

• Thrombocytopenia
• Immunosuppression
• Leukopenia
• Anemia
• Cardiac Toxicity
• Pulmonary Toxicity

9
Management of AnesthesiaPreop tests in patients
with Cancer

• Hematocrit
• Platelet count
• WBC
• PT
• Electrolytes
• Liver Function tests
• Renal Function tests
• BG, ABG,CXR, EKG

10
Preoperative Preparation

• Correct
• Nutritional deficiencies
• Anemia
• Coagulopathy
• Electrolyte abnormalities
• Control Nausea and Vomiting
• Metoclopramide
• Droperidol
• Zofran

• Tricyclic antidepressant (potentiate opioids)
• Opioids may cause preop sedation)
• Presence of renal/hepatic dysfunction may
  influence choice of anesthetic drugs and muscle
  relaxants.

11
Preoperative Preparation 2

• Possibility of prolonged responses to
  succinylcholine is a consideration in patients
  being treated with alkylating chemo drugs.
• Attention to anesthesia aseptic technique due to
  immunosuppression.
• Immunosuppression produced from anesthesia,
  surgical stimulation, and blood transfusions may
  exert undefined effects on the patients
  subsequent responses to cancer.

12
Pulmonary and Cardiac Toxicity

• Preop pulmonary fibrosis and CHF would influence
  conduction of anesthesia.
• -patients on bleomycin have a risk of
  interstitial pulmonary edema due to impaired
  lymphatic drainage owing to drug induced
  pulmonary fibrosis (monitor ABGS and SPO2).
• Depressant effects of anesthetic drugs on
  myocardial contractility maybe enhanced in
  patients with drug induced cardiac toxicity.

13
NeurotoxicityPeripheral neuropathyEncephalopathy

• Vinca alkaloids(vincristine) causes peripheral
  neuropathy causing parasthesias in digits.
• - ANS neuropathy may be affected.
• Cisplastin causes dose-dependent large-fiber
  neuropathy by damaging dorsal root ganglia.
• Corticosteroids dosages at 60 to 100 mg daily may
  cause a myopathy characterized by weakness
  causing difficulty standing and sitting and
  respiratory muscles maybe affected!

14
Encephalopathy

• High dose cyclophosphamide maybe associated with
  acute delirium.
• High dose cytarabine may cause acute delirium or
  cerebellar degeneration which is reversible.
• Reversible acute encephalopathy may accompany IV
  or interthecal administration of methotrexate
  especially in conjuction with radiation therapy
  and can lead to dementia.

15
Common Cancers in Clinical Practice

• Lung Cancer
• Breast Cancer
• Colon Cancer
• Prostate Cancer

16
Lung Cancer

• Leading cause of cancer deaths among men and
  women.
• 1/3 of all cancer deaths.
• More than 90 related to cigarette smoking.
• High mortality related to its aggressive biology
  and advanced state when diagnosis confirmed.
• Mutagens of carcinogens present in cigarette
  smoke causes chromosomal damage/CA.
• Other causes are ionizing radiation, radiation
  (for breast CA), asbestos and radon gas.

17
Lung CAncer

• Cessation of cigarette smoking decreases
  incidence of lung cancer to that of non smokers
  after 10 to 15 years have elapsed.
• Second hand smoke increases incidence of lung ca
  and increases childhood respiratory infections.
• Development of emphysema increases incidence of
  lung CA.
• AIDS increases risk of lung CA.

18
Signs and symptoms

• Cough, hemopysis, wheezing, stridor, dyspnea, or
  pneumonitis.
• Mediastinal metastasis causes hoarseness (RLN
  compression), superior vena cava syndrome,
  dysrrhythmias, CHF from pericardial effusion and
  tamponade.
• Generalised weakness, anorexia and weight loss
  are common.

19
Diagnosis

• Cytologic analysis of sputum is often sufficient
  for diagnosis.
• Lesions as small as 3.0 mm can be detected by
  high resolution CT scan.
• Flexible fiberoptic bronc with biopsy.
• Video assisted thoracoscopic surgery.
• Mediatinoscopy to examine lymphnodes.

20
Lung Cancer

• Healthy lung

• Lung cancer

21
Management of Anesthesia

• Evaluate underlying pulmonary and cardiac
  function when lung resection is planned.
• If mediastinoscopy, monitor for hemorrhage,
  pneumothorax, VAE, pressure on right subclavian
  artery and carotid artery.
• Prepare to place a DLT for a thoracotomy in order
  to isolate the lung, keep ETCO2 35-45, PIP lt35 cm
  H2O.
• Large bore IVS X2, Aline .
• Standard induction STP or propofol, succs or
  Roc.
• O2, iso and iv opioids.
• Epidural or intercostal block.
• Extubate in OR, transfer in head up position to
  PACU or ICU.

22
Colorectal Cancer

• Second cause of death after lung cancer.
• Adults older than 50years. 25 familial.
• 99 are adenocarcinomas.
• Polyps greater than 1.5cm are more likely to
  contain invasive cancer.
• Diet related, upper socioeconomic, living in
  urban areas.
• Direct correlation between calories consumed,
  dietary fat/oil, and meat protein.
• IBS, Smoking greater than 35 years.

23
Colon Cancer

• Colonoscopy Diagnosis.
• Colon CA spreads to regional lymph nodes,
  portal circulation, liver, lungs, bones, brain.
• Preoperative increases in CEA. (carcinoembryonic
  antigen), suggest that tumor will reoccur
  following resection.
• CEA is also increased in other cancers (stomach,
  pancreatic, breast, lung) and non malignant
  conditions such as alocholic liver disease, IBS,
  smoking and pancreatitis.

24
Colon Cancer
25
Anesthesia Management

• GETA with epidural for post op pain if possible.
• If acute abdominal process RSI or awake
  intubation.
• Maintenance, combined epidural with GA.
• Decision to extubate depends on underlying
  cardiopulmonary status.
• Anticipate large 3rd space losses, large bore IVS
  x2, monitor UOP.
• TC for 4 units PRBC.

26
Anesthesia Management

• Disease induced anemia. Metastasis to liver,
  lungs, bones or brain.
• Chronic large bowel obstruction does not increase
  risk of aspiration during induction, but may
  interfere with V/O.
• Blood transfusions are associated with decreased
  survival probably from immunosuppression from
  transfused blood.

27
Prostate Cancer

• Second leading cause of death among men.
• Increased number of reported cases due to using
  prostate-specific antigen (PSA) testing.
• Highest in african americans lowest incidents in
  asians.
• Mostly discovered during autopsy as asymptomatic.
• Hereditary prostate cancer gene (HPC-1) increases
  the risk.

28
Prostate Cancer

• Previous vasectomy has been reported as a risk
  factor to prostate cancer but has not been
  substantiated
• Prostate cancer is always an adenocarcinoma
• Treatments include
• -Transurethral resection
• -Radical prostatectomy or radiation

29
BPH
30
Anesthetic management

• TURP
• Regional or GA depends on coexisting disease and
  patient preference.
• Regional anesthesia maybe better in order to
  evaluate mental status to detect TURP syndrome.
• SAB T9 level is optimal using 0.5 bupivacaine
  12mg in dextrose 7.5 solution.
• TURP should not exceed 2hrs due to absorption of
  irrigation fluid.

31
More anesthetic management

• Standard induction.
• Muscle relaxation is not mandatory but patient
  movement must be avoided.
• Anticipate BP drop when legs are dropped from
  lithotomy position.
• Blood loss can be large if venous sinuses are
  entered, difficult to quantify with irrigation.
• Invasive monitoring depends/patient condition.
• Signs of bladder perforation, such as shoulder
  pain in awake patient, maybe unnoticed under GA,
  may see increased HR and BP, sometimes low BP.
• Minimal post op pain.

32
Open prostate operations

• Usual preop diagnosis is BPH and prostate CA.
• Regional technique, GA or combined technique is
  used.
• Optimal block T8-T10.
• Under GA standard induction.
• Moderate blood loss expected with larger glands
  30-80g have patient have blood available.
• Have 2 large bore IVs.
• CVP for volume status assessment.
• Arterial lines for continuous BP measurement and
  labs.
• Commonly used drugs (digitalis, b-blockers,
  diuretics, NTG) to prevent cardiovascular
  complications.

33
Breast Cancer

• Most women diagnosed with breast cancer do not
  die from it cure rate is 70.
• It is estimated that 2 million in the US people
  are living with breast cancer.
• 75 of cases occur in patients older than 50
  years of age.
• Family history (a first degree relative diagnosed
  when younger than 50 years increases the risk 3
  to 4 fold).
• Reproductive risk factors include early menarche,
  late menopause, late first pregnancy, nulliparity
  due to prolonged exposure of breasts to estrogen.

34
Screening and prognosis

• Self breast exam.
• Clinical breast exam by a professional.
• Screening mammography (recommended if older than
  40years.
• 10-15 of breast cancers are not picked up by
  mammography, MRI, US maybe needed.

35
Breast CA

• Axillary node status and tumor size determine
  outcome in patients with breast CA.

36
Treatments

• Lumpectomy with radiation.
• Modified radical mastectomy (with removal of
  breast and axillary nodes).
• Sentinel node dissection (dominant axillary
  node). If negative further axillary node
  dissection can be avoided.
• Radiation therapy accompanies lumpectomies due to
  reccurence.
• Radiation post mastectomy is not recommended due
  to cardiac toxicity.

37
Breast Cancer
38
Management of anesthesia

• Side effects of chemotherapy should be
  evaluated.
• IV lines should be avoided in ipsilateral arm to
  avoid exacerbation of lymphedema.
• Bone pain and pathological fractures should be
  considered when selecting regional anesthesia.
• Preop opioids help with pain management prior to
  surgery.
• Isosulfan dye used for localization can decrease
  pulse oximetry transiently.
• Anesthetic drugs, techniques, and monitoring
  depends on planned surgical procedure and pts
  current condition.

39
Anesthesia for breast biopsy and sentinel node
biopsy

• MAC with local anesthesia.
• GA with local anesthesia for post op pain
• -Mask, LMA or ETT.
• Muscle relaxants not necessary.
• Minimal blood loss.

40
Anesthesia for Breast-conserving surgery,
mastectomy and reconstruction

• GETA or GA with LMA.
• Regional anesthesia with paravertebral block
  (PVB) in breast surgery is associated with less
  PONV, less pain and earlier discharge.
• Standard induction.
• Use of muscle relaxants during axillary
  dissection should be avoided to allow
  identification of nerves by nerve stimulator.
• Risk of pneumothorax.
• High incidence of PONV so medicate appropriately.
• Minimize coughing on emergence to decrease post
  op bleeding.

41
Less Common Cancers Encountered in Clinical
Practice

• Cardiac Tumors
• Cardiac Myxomas
• Metastatic Cardiac Tumors
• Primary Malignant Tumors
• Head and Neck Cancers
• Thyroid Cancer
• Esophageal Cancer
• Bone Cancer
• Multiple Myeloma
• Osteosarcoma
• Ewings Tumor
• Chondrosarcoma

• Gastric Cancer
• Liver Cancer
• Pancretic Cancer
• Renal Cell Cancer
• Bladder Cancer
• Testicular Cancer
• Uterine Cervix Cancer
• Uterine Cancer
• Ovarian Cancer
• Cutaneous Cancer

42
Less common cancersCardiac myxomas

• Accounts for ½ of all benign cardiac tumors in
  adults.
• 70 occur in LA and 30 in RA.
• Symptoms interfere with filling and emptying of
  involved cardiac chamber.
• Also release of myxomatous material from the
  tumor or thrombi that have formed in the tumor.
• LA myxomas mimic mitral valve disease with
  development of pulmonary edema.
• RA myomas mimic tricuspid disease causing
  impaired venous return and evidence of right
  heart failure.
• Embolism occurs in 30 to 40 of patients.

43
Diagnosis and treatment

• Incidental diagnosis during intraop TEE.
• Cardiac myxoma tumors are at least 0.5 to 1.0 cm
  in diameter can be identified by CT and MRI.
• Surgical resection is curative and should be done
  ASAP.
• Mechanical damage to the heart valve or adhesion
  of tumor to the heart valve necessitates valve
  replacement.

44
Anesthetic management

• Possibility of low cardiac output and arterial
  hypoxemia from obstruction at the tricuspid
  valve.
• RA myxoma prohibits placement of RA or PA
  catheters.
• SVT dysrhythmias and conduction disturbances may
  occur.

45
Anesthetic management

• GETA
• Aline placement prior to induction.
• Moderate to high dose narcotic (fentanyl
  10-100mcg/kg or sufentanil 2.5-20mcg/kg),
  midazolam (50-350mcg/kg).
• Etomidate (0.1-0.3mg/kg), Vecuronium or
  pancuronium (0.1mg/kg) depending on desired HR to
  facilitate intubation.
• Use of fluid to treat low BP ok but consider
  pulmonary edema.
• Phenylephrine to maintain SVR.
• Maintain sinus rhythm.
• Maintain case with narcotic, low dose isoflurane
  and oxygen with air as tolerated.
• Standard monitors PAC, TEE, foley catheter.
• TC patient and have blood in the room.

46
Postoperative Considerations

• Postoperative mechanical ventilation following
  invasive or prolonged operations and in patients
  with preoperative drug-induced pulmonary
  fibrosis.
• Drug induced cardiac toxicity patients are more
  likely to experience postop cardiac complications.

47
Acute and Chronic Pain

• Acute pain is associated with pathological
  fractures, tumor invasions, surgery, radiation
  and chemo.
• Metastatic cancer pain especially to bone.
• Nerve compression of infiltration may cause pain.
• Signs of depression and anxiety.

48
Pathophysiology of pain

• Norciceptive pain
• -Somatic and visceral pain due to stimulation
  of norciceptors in somatic or visceral
  structures
• -Somatic pain involves bone or muscle pain
  described as aching, stabbing or throbbing
• -Visceral pain is in a hollow or solid viscus
  described as diffuse, crampy or gnawing.
• -Responds to opioids and nonopioids
• Neuropathic pain
• -Involves peripheral nerves or central
  afferent neural pathways described as burning or
  lancinating pain
• -Respond poorly to opioids.

49
Treatment

• Drug therapy such as NSAIDS and acetaminophen for
  mild to mod pain.
• Codeine for management of mod to severe pain.
• Opioids for severe cancer pain such as morphine
  and fentanyl.
• Tricyclic antidepressants for patients who remain
  depressed even when pain is controlled.
• TCAs are useful since they potentiate opioids.
• Anticonvulsants are useful for management of
  chronic neuropathic pain.
• Corticosteroids can lower pain perception
  decreasing need for opioids, improve mood,
  increase appetite and weight gain.

50
Treatment

• Neuraxial administration
• -Morphine epidurally or intrathecaly.
• -Implantable infusion devices when systemic
  infusions have failed.
• Neurolytic procedures
• -Destroying sensory component of nerves using
  nerve blocks.
• -Celiac plexus blocks for pain originating in
  abdominal viscera.
• -Dorsal column stimulators or deep brain
  stimulators can be used.

51
Paraneoplastic Syndromes

• Superior Vena Cava Syndromes
• Increased ICP
• Pericardial Tamponade
• Renal Failure
• Hypercalcemia

52
Pathophysiologic Manifestations of Paraneoplastic
syndromes

• Fever, Anorexia, Weight Loss, Anemia
• Thrombocytopenia, Coagulopathies
• Neuromuscular abnormaities
• Ectopic hormone production
• Hypercalcemia
• Hyperuricemia
• Tumor lysis syndrome
• Adreneal insufficiency

• Nephrotc Syndrome
• Utereral syndrome
• Pulmonary hypertrphic osteoarthropathy /clubbing
• Pericardial effusion, Pericardial tamponade
• Superior vena cava syndrome
• Spinal cord compression
• Brain metastasis

53
Fever and Weight Loss

• Fever with any CA, but is particularly likely
  with mets to the Liver.
• Increases body temp, lactic acidosis may
  accompany rapidly proliferating tumors (leukemias
  and lymphomas).
• Fever may reflect tumor necrosis, inflammation,
  the release of toxic products by CA cells, and
  production of endogenous pyrogens.
• Anorexia and wt loss, especially with lung CA.

54
Carcnoid Tumor and Carcinoid Syndrome

• Slow growing malignancies of enterochromaffin
  cells usually found in the GI tract. (lung,
  pancreas, thymus, liver).
• Increased use of PPI ?cause.
• GI tract 2/3 of of carcinoids (small intestine
  41.8, rectum 28,stomach 8.7).
• Tumors secrete biologically active substances
  serotonin, histamine, prostaglandins,
  adrenocorticoptropic hormone, gastrin,
  calcitonin, and growth hormone.
• 5-10 develop carcinoid syndrome.

55
Carcinoid Syndrome Manifestations

• Episodic cutaneous flushing (kinin, histamine)
• Diarrhea
• Heart Disease
• Tricuspid regurgitation, pulmonic stenosis
• SVT
• Bronchoconstriction

• Hypotension
• Abdominal Pain
• Hypertension
• Hepatomegaly
• Hyperglycemia
• Hypoalbuminemia
• Vasoactive peptids released from carcinoid tumors
  in bronchi and ovaries

56
What 2 factors enhance release of carcinoid
hormones?

• Direct physical manipulation of the tumor.
• Beta Adrenergic stimulation.

57
Anesthesic Considerations in Carcinoid Syndrome

• Most common clinical signs are flushing,
  wheezing, Bp HR Changes, and diarrhea.
• Preop assessment CBC, Lytes, Liver function
  tests, BG, EKG, Urine 5 HIAA levels.
• Optimize fluid and lytes. Pretreat with
  Octreotide. Continue in post op period.
• Both Histamine 1 and 2 receptor blockers must be
  used fully to block histamine effects.
• Avoid histamine releasing agents
  MSO4,Thiopental, Atracurium.
• Avoid sympathomimetic agents ketamine and/or
  ephedrine.
• Treat Low BP with alpha-receptor Neo

58
Carcinoid Syndrome

• GA over RA. Pts with high serotonin levels have
  prolonged recovery, use des or sevo for rapid
  recovery.
• Aggressively maintain normothermia to avoid
  catecholamine-induced vasoactive mediator
  release.
• Monitor BG intraoperatively, prone to
  hyperglycemia.

59
Octreotide

• Somatostanin analog is used to blunt the
  vasoactive and bronchoconstrictive effects of
  carcinoid tumor products.
• TX 2 weeks before OR dose of 100mcg SQ TID
• 50 to 150 mcg SQ preop. 100mcg/hr infusion.
• 100 to 200mcg IV for intraop carcinoid crisis.
• Bronchospasm (histamine or bradykinin) have shown
  to be resistant to ketamine or inhalation agents.
  Use Beta 2 agonists for bronchodilitation.

60
Superior Vena Cava Obstruction

• Engorgement of veins above the waist,
  particularly jugular veins.
• Dyspnea, airway obstruction.
• Facial and arm edema.
• Hoarseness may reflect edema of the vocal cords.

61
Spinal Cord Compression

• Metastatic lesions in the epidural space, most
  often relflecting breast, lung, prostate cancer
  or lymphoma.
• Pain, Skeletal muscle weakness, sensory loss,
  autonomic nervous system dysfunction.
• Corticosteroids, radiation, MRI, CAT,
  Myelography.

62
Increased ICP

• Nausea
• Seizures
• Decreased level of consciousness
• Mental deterioration
• Focal neuro deficits
• CAT scan, corticosteroids, diuretics, mannitol
• Radiation, Intrathecal Chemo

63
Cancer

• Does Anesthetic Management affect Cancer Outcomes?

64
The Stress Response and CANCER

• Immune response is controlled by cytotoxic T
  lymphocytes, NK (natural killer) cells,
  NK-T-cells, dendritic cells and macrophages.
• Inflammatory mediators such as interferon (INF)
  and interleukin (IL) increase the activity of T
  and NK cells.
• B-adrenergic stimulation which increases during
  stress states suppresses NK activity and so
  promotes metastasis.
• Low NK activity increases cancer morbidity and
  mortality.

65
Surgery, Anesthesia and CANcer Metastasis

• Surgery suppresses immunity and so promotes
  metastasis.
• Surgical stress promotes angiogenesis and
  contributes to neoplastic growth.
• Minimally invasive procedures might be better for
  cancer patients.

66
Anesthetic Drugs

• A study in rats showed that ketamine, thiopental,
  and halothane reduced NK cell activity and
  increased lung metastasis.
• The effect of ketamine might be due to adrenergic
  stimulating properties.
• Propofol does not promote metastasis may be due
  to its weak beta adrenergic antagonist
  properties.

67
Anesthesia Animal Studies

• Morphine promotes angiogenesis and promotes
  breast tumor growth in rodents.
• Pain relief decreases metastasis susceptibility
  due to reduction in stress response.
• It is now know that opioids inhibit cellular and
  humoral immune function in humans.

68
Anesthesia Animal Studies

• Decreases use of inhaled agents and opioids which
  decrease NK cells.
• Opioids administered intrathecally in small
  quantities do not have the same effect on NK
  cells.
• Decreases release of catecholamines which reduce
  NK cell activity.
• Epidural anesthesia improves post op outcomes by
  decreasing surgical stress.
• In a study of mice a laparatomy procedure using
  sevo increased liver mets as compared to sevo and
  spinal anesthesia.

69
Neuraxial Anesthesia Human Data

• Use of paravertebral anesthesia and analgesia for
  breast cancer decreases risk of reoccurence.
• A study on men undergoing a prostatectomy under
  GA with morphine compared to GA with epidural
  anesthesia, epidural technique was associated
  with a 65 reduction in biochemical recurrence of
  prostate CA.

70
Neuraxial Anesthesia Human Data

• Spinal anesthesia for a TURP resulted in less
  immunosupression after surgery.
• If reducing volatile anesthetic requirements or
  opiates is vital, use of dexmedetomidine or IV
  lidocaine might be beneficial.

71
Conclusion

• Our anesthetic drugs and approaches may impact
  tumor metastasis after cancer surgery. Techniques
  that prevent stress responses and increase
  catecholamine, and that limit requirements for
  volatile anesthetics and opiates, seem effective
  in reducing the incidence of metastasis.
• Since 90 of cancer related death is due to
  metastatic development rather than primary
  cancer, then potential for improving patient
  outcome is very significant.

72
Case Study

• 50 year old female, Ima Goner undergoing primary
  resection of the small intestine tumor. She has
  been on Proton Pump Inhibitor for 10 years, and
  was recently diagnosed at the SDSC via
  colonoscopy. Labs include H/H 9.8/31. Na 140,
  K 3.9, BG, 153. During tumor removal the
  patient becomes hard to ventilate, wheezes are
  detected, BP goes to 70/40, HR 112, code brown
  ensues.What is the most common clinical scenario
  happening?

73
Case Study

• Preoperative Assessment for this case should have
  included what 6 to 7 tests?
• CBC
• Electrolytes
• LFTs
• BG
• EKG (Echo if indicated)
• Urine 5-HIAA levels
• What drug should this patient have been treated
  with? How long?
• Octreotide
• Treatment 2 weeks pre-op 100mcgs SQ
• Anesthestic drugs of choice for this case
  include STP, MSO4, Atricurium, Ketamine,
  Ephedrine, Halothane, Isoflurane.
• True or False?

74
Case Study

• What two drug catagories/blockers must be
  utilized to fully counteract histamine release?
• H1 and H2 Receptor Blockers
• Treat hypotension with what drug?
• Alpha Receptor Agonist- Neo
• What temperature should this patient be
  maintained?
• Normothermic
• What lab should be assessed during the case?
• BG

75
Question 1

• An otherwise healthy patient is undergoing a
  small bowel resection for tumors and develops
  bronchoconstriction, cutaneous flushing of the
  face and neck, and supraventricular
  tachydysrythmias during manipulation. The most
  likely cause of these signs is
• A. Acute asthma attack
• B. Anaphylaxis reaction
• C. Carcinoid syndrome
• D Autonomic hyperreflexia

76
Rationale

• C Carcinoid syndrome
• Manifestations of carcinoid syndrome include
  cutaneous flushing (kinins, histamine),
  supraventricular tachydyshythmias (serotonin),
  Bronchoconstriction (serotonin, bradykinin,
  substance P).

77
Question 2

• Treatment of hypotension in a patient
  anesthetized for resection of metastatic
  carcinoid would be best accomplished with?
• A Epinephrine
• B Ephedrine
• C Somatostatin
• D Angiotensin

78
Rationale

• C Somatostatin
• Suppresses the release of serotonin and other
  vasoactive substances from the tumor.

79
Question 3

• A 55 year old is to undergo a TURP under general
  anesthesia. The patient has a 40 pack year
  smoking history and a history of CHF. The patient
  receives Reglan and Scopolamine preoperatively.
  General anesthesia is induced with Ketamine the
  procedure is uneventful. In PACU the patient
  complains of inability to see objects up
  close.The most likely cause would be?

80
Question 3

• A Effects of scopolamine
• B Emergence delirium from ketamine
• C Effects of glycine in the irrigating solution
• D Corneal abrasion
• E Hyponatremia

81
Rationale

• A Effects of Scopolamine
• Scopolamine is an anticholinergic that may
  produce mydriasis and can result in patients
  inability to accommodate.

82
Question 4

• Induction of anesthesia in the cancer patient
  being treated with alkylating chemo drugs may
  exhibit one of the following complications
• A. Decreased urinary output.
• B. Increased HR and BP.
• C. Decreased BP and bradycardia.
• D. Prolonged response to Succinylcholine.

83
Rationale

• D Prolonged response to Succinylcholine.

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Question 5

• Cancer patients on large doses of corticosteroid
  may exhibit the following on emergence
• A Respiratory weakness.
• B Cardiac dysrrhythmias.
• C Prolonged effect of narcotics.
• D Decreased sodium and water retention.

85
Rationale

• A Respiratory Weakness.
• Corticosteroids cause a myopathy characterized by
  weakness causing difficulty standing sitting and
  respiratory muscles may be affected.

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• Sing
• As though no one can hear you.
• Live
• As though heaven is on earth.
• Dance
• As though no one is watching you.
• Love
• As though you have never been hurt before.
• Mark Twain