6.6 Splenectomy + Lymphoma

Question 1

A 26-year-old patient with stage 4B Hodgkin’s disease (spread to lymph nodes and other organs)
requires an open splenectomy.

a) List the specific factors that are of importance when planning your anaesthetic management.
(10 marks)

A-D

Answer 1

Airway:
» Upper airway may be compromised by lymph nodes in neck/oropharynx.

Meticulous airway assessment.

>> Potential for airway compromise by 
mediastinal mass
 (cough, dyspnoea,
hoarse voice, orthopnoea, 
syncope with positional change or no
symptoms at all). 

Compression may be at the
tracheal or bronchial level.

Establish what position the patient
is least symptomatic in.

Assess with CT thorax.

Plan A may include keeping the
patient spontaneously
ventilating until airway secured,

plan B rigid bronchoscopy.

> > May have mucositis from chemotherapy. Care with airway instrumentation.

Respiratory:
» Risk of atelectasis and pneumonia due to airway collapse caused by lymph nodes and immunocompromised state. CXR, CT thorax.

> > Bleomycin confers lifelong susceptibility to pulmonary toxicity with exposure to high oxygen concentrations.
Oxygen saturations to be
maintained at 88%–92%, minimising supplemental oxygen where feasible.

Cardiovascular:
>> Compression of major vessels or even 
heart due to mediastinal lymph
nodes:
 risk of cardiovascular collapse
 under anaesthesia. 

Check CT thorax.

> > Risk of cardiac dysfunction due to chemotherapy.

> > Mediastinal radiotherapy may cause
damage to valves, vessels, pericardium.

Echo to check for myocardial compression,
ventricular dysfunction and pericardial effusion.

> > May have central venous access/
port for chemotherapy.

Neurological:
» Risk of compression of nerves and
even spinal cord by lymphoma mass.

> > Risk of peripheral or autonomic neuropathies
(effect on gastric emptying, may necessitate
antacid premedication and RSI)
due to chemotherapeutic agents.

Question 2

b) Outline the options for providing postoperative analgesia for this patient and give a possible
disadvantage of each. (6 marks)

Answer 2

paracetamol - 1g qds
liver dysfuction in patient where may already be mets / dysfunction

nsaid ibuprofen 400mg tds - may be exisitng renal impairement can worse

Opiates - morphine pca / oral morphine
resp depresssion / ileus / constipation

Nerve block + wound cathter - nerve injury / chance infection

thoracic epidural - pdph

Oral analgesics: 
insufficient on their own. 
NSAIDs may be contraindicated
in the presence of renal dysfunction; 
paracetamol dose may need
adjusting in the presence of liver dysfunction. 

Oral morphine may accumulate in the
presence of renal dysfunction.

> > Epidural analgesia:
may be contraindicated due to thrombocytopaenia
and even coagulation disturbance
if there is liver involvement.

Cardiovascular instability may occur
as high block would be required.

High block may compromise respiratory function if the patient already has compromise due to mediastinal disease

> > Paravertebral block:
avoids the cardiovascular instability that may result from epidural but may still be contraindicated due to thrombocytopenia or disordered clotting.

> > Patient-controlled analgesia (PCA):
may need high doses to achieve
adequate pain relief.
Long-acting opioid such as morphine may
accumulate in the presence of renal dysfunction, causing respiratory compromise, narcosis.
Fentanyl or oxycodone PCA may be an alternative.

> > Rectus sheath and transverse abdominis plane blocks: do not manage visceral pain but have a role in reducing analgesic requirements.
Might not achieve cover of proximal end of wound.
May be feasible at platelet
levels where neuraxial blocks would be contraindicated.

Question 3

a) List the specific factors that are of importance when planning your anaesthetic management.
(10 marks)

F - L

Answer 3

Pharmacology:
» Consider the side effects of chemotherapy.

Gastrointestinal:
>> May be malnourished due to anorexia 
associated with treatment, painful
mouth due to mucositis,
 fullness of abdomen from splenomegaly.

Haematological:
» May be pancytopenic, with
low platelets and low haemoglobin.

This may need to be corrected prior to surgery.

Regional anaesthesia may be
contraindicated.

> > Significant blood loss may be encountered intraoperatively.
Plan for adequate intravenous access
and cross-match.

Immune, infection:
» Immunocompromised due to disease and chemotherapy; assess for intercurrent infection. Meticulous infection control essential.

Cutaneomusculoskeletal:
» Thrombocytopaenia associated with easy bruising, bleeding from minor cuts etc.
Care with positioning and padding.

>> Patient may be oedematous from 
ypoalbuminaemia associated with
liver impairment or nephrotic syndrome. 
Thin, fragile overlying skin,
difficulty with venous access.

Renal:
» Risk of renal dysfunction due to chemotherapy.

> > Risk of nephrotic syndrome,
obstruction of renal vessels or ureters,
lymphogranulomatous infiltration of parenchyma, amyloid and consequent renal dysfunction.

> > Renal dysfunction impacts on perioperative drug choices and increases the importance of avoiding dehydration and hypotension as these
compound the nephrotoxic process.

Liver:
» Risk of liver dysfunction due to chemotherapy or disease: may result in disordered coagulation, may contraindicate regional anaesthesia, may
impact on anaesthetic drug handling.

Question 4

Preamble for Hodgkins lymphoma

Answer 4

Hodgkin’s Lymphoma:
» Cancer of the lymphatic system
therefore presenting with
lymphadenopathy, splenomegaly, hepatomegaly.

> > B symptoms:
fever, night sweats,
weight loss, itch, fatigue.
Stages:

• I: single lymph node involvement
(or Ie, single extralymphatic site).

• II: two or more lymph nodes,
same side of the diaphragm
(or one lymph node plus contiguous
extralymphatic site IIE).

• III: lymph nodes on both sides of diaphragm,
which may include the
spleen (IIIS) and/or contiguous
extralymphatic site (IIIE, IIIES).

• IV: disseminated involvement of
one or more extralymphatic organs,
e.g. liver.

• If B symptoms absent, 
add A to the stage;
 if present, B. 
S denotes splenic involvement; 
X, bulky disease.

• Treatment is with chemo- and radiotherapy.

• Splenectomy may be indicated
due to its sheer size or hypersplenism,
i.e. excessive destruction of blood cells and platelets.

Question 5

c) Which vaccinations should this patient receive and what is the optimal timing of these? (4 marks)

Answer 5

Initial vaccinations at least two (ideally four to six) weeks preoperatively, or two weeks afterwards, and three months after completion of chemo- or
radiotherapy:

> > Haemophilus influenza b.
Pneumococcus (booster dose every five years).
Meningitis B and C.

Annually:
» Influenza.