6.1 Ovarian Malignancy w/ Ascites Flashcards
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
b) intraoperative (25%) and
c) postoperative management (25%) of this patient?
Pre-Op
Assessment
Airway - dental injury / condition from CTX
B -
may have intrapulmonary pathology CTX
restrictive lung dis - consider PFTs
ventilation affected by ascites?
C
Pre Op Echo - CTX induced myopathy
Functional status - METs as indicator of baseline
D
Any peripheral neuropathy
E
F
Haem - FBC looking for CTX induced anaemia / neutropaenia
platelet dysfunction
G
Nausea / vomiting
ascites - work up cause
does it need drainage
Malnourished / nutrition - normal BMI with abnormal large ascites
LFTs - ?mets
I - increased risk infection
Kidney - U+ E sent to discover any underlying kidney dysfunction from ctx
Imaging - CT TAP / PET scan - disease progression / mets
Blood - group and x match
ecg - cardiac arrytyhmia from ctx / malnutrition
Conset and discussion around analgesia / post op destaination risks
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
Airway:
» Massive ascites will increase risk of reflux – may require draining
preoperatively.
Respiratory:
» Pleural effusion. Assess for likelihood: assess exercise tolerance, auscultate and percuss chest. However, the patient is likely to have recent imaging that will show effusions. Significant effusions can be drained preoperatively to improve lung function.
> > Massively reduced functional residual capacity due to ascites. Affects V/Q matching and causes basal atelectasis. Consider need to drain preoperatively.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
Cardiac
Cardiac:
» Assess for cardiotoxic effects of paclitaxel and cisplatin. Assess exercise
tolerance, echo.
» Pericardial effusions. May be indicated by small complexes on ECG and
detected on echo.
» Indwelling venous access may already be in situ for chemotherapy. Need
to consider when deciding where to place lines for operation. Veins may
be difficult to cannulate due to previous treatment and use.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
Pharmacology
Pharmacology:
» Paclitaxel and cisplatin cause bone marrow suppression (check full blood
count), renal damage (check urea and electrolytes), liver dysfunction (check liver function tests and coagulation), and cardiotoxicity (request
echo). Discuss with oncologist regarding any other effects of any chemotherapeutic agents that have been received.
> > Diuretics may have been used to attempt to alleviate effusions and ascites; therefore, check for electrolyte imbalance that may need correcting.
> > Antiemetics: may already be being used to manage nausea and vomiting associated with chemotherapy. Ensure uninterrupted treatment
perioperatively.
> > Opioids: may already have opioid requirement, which will have to be considered when planning postoperative analgesia.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
Haematological:
Haematological:
» Risk of deep vein thrombosis (procoagulant factors released in
cancer state, venous obstruction due to intra-abdominal mass and
ascites). Some patients may have already been receiving prophylaxis.
Perioperative prophylaxis plan needs addressing.
» Liver dysfunction may cause coagulopathy: check clotting, manage
appropriately.
» Risk of significant bleeding with removal of many intra-abdominal and
pelvic organs. Cross-match preoperatively.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
Immune, infection:
Renal:
Immune, infection:
» Bone marrow suppression:
renders patient at greater risk of infection.
Assess for possible infections preoperatively.
Renal:
» Risk of renal toxicity from chemotherapy.
If there is renal impairment,
consider impact on drugs to be used intraoperatively.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
a) preoperative (50%),
Liver:
» Risk of liver dysfunction from chemotherapy, from cholestasis secondary
to massive ascites and from malignant deposit. Check liver function
tests. Consider impact on choice of drugs to be used.
Nutrition:
» Malnutrition and dehydration risk due to anorexia, chemotherapy, ascites.
May need intravenous fluid preoperatively and dietician involvement from
the outset.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Airway:
» Intubate: major, prolonged, abdominal surgery, sometimes head down
position, risk of reflux from raised intra-abdominal pressure.
Respiratory:
» Reduced functional residual capacity due to ascites. Ensure thorough
pre-oxygenation in head up position.
» Capnography and arterial blood gas monitoring to target adequate
ventilatory parameters, care with high airway pressures due to ascites
(until abdomen opened).
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Cardiac:
» Two large cannulae – risk of significant bleeding.
> > Arterial line: beat-to-beat blood pressure monitoring and electrolyte monitoring useful in face of large fluid shifts.
> > Cardiac output monitoring: massive fluid shifts due to further loss of ascites (this must be done slowly) and large amounts of tissue removal.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Neurological:
Neurological:
» Pain management: NSAIDs and paracetamol may be contraindicated if there is renal and liver dysfunction. May already be on opioids; therefore,
higher doses may be required.
Avoid renally excreted opioids in the presence
of significant renal dysfunction.
Consideration of epidural if clotting permits.
Consideration of rectus sheath catheters for opioid-sparing effect.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Haematological
Haematological:
> > Significant blood loss may occur due to ooze from many tissue surfaces.
Monitor with near patient testing for haemoglobin and coagulation.
> > Risk of DVT: automated intermittent
leg compression devices intraoperatively.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Immune, infection:
Cutaneomusculoskeletal:
Immune, infection:
» Bone marrow suppression renders patient at greater risk of infection.
Scrupulous asepsis required.
Cutaneomusculoskeletal: >> Prolonged surgery, care with positioning and padding. Care if known bony metastases.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Renal:
Renal:
» Catheterise to monitor urine output
to assist with managing fluid balance
in the presence of significant fluid shifts.
> > Use of drugs whose metabolism
is independent of renal function if
patient has renal impairment,
e.g. remifentanil infusion, atracurium.
> > Risk of liver dysfunction; consider drug suitability before giving.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Intraoperative
Metabolic:
» Prolonged surgery: monitor temperature, use under body warming
mattress, warmed fluids, insulating hat.
» Arterial blood gas analysis to monitor lactate and base excess in the
presence of large fluid shifts.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of
primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the
Post Op
Consideration of location of postoperative care:
level 1 or 2 if, for example, there has been significant blood loss or if there is significant preoperative or
intraoperative organ dysfunction. May possibly need level 3 care.
