Anesthesia Implications r/t Oncology and Chemotherapy Flashcards
Form normal cells to cancer undergoes what chances
Numbers of cells increases vs. how cells are organized increases
normal-> hyperplasia-> dysplasia-> cancer
hyperplasia = extra cell growth but organized
Dysplasia = disorganization starts
Cancer is a collection of _____ and what happens to the cells is ______
A collection of related diseases
Body cells that begin to divide without stopping and spread into surrounding tissues.
May form solid tumors or not (leukemias)
Generic causes of cancer
Inherited from parents
Mutations to DNA
Cancer cells features (3)
Less specialized; easier to divide/ ignore apoptosis signals
Abnormally influence normal cells (angiogenesis)
Can evade the immune system
What increases/ speeds up cancer/ increases proliferation of cancer cells
Proto-oncogenes
Tumor suppressor genes
DNA repair genes
Proto-oncogenes do what?
Involved in normal cell growth and division
Become cancer-causing…allow cells to grow and survive
Tummor supressor genes do what?
Alterations allow genes to divide uncontrollably
DNA repair genes do what?
Incorrect damage repair; cause other mutations
Basal cell cancer
basal (base) layer of epidermis
Squamous cell:
squamous cells (epithelial cells) that lie just beneath skin
Also line stomach, intestines, lung, bladder
Adenocarcinoma
cells that produce mucous
Glandular tissue: breast, prostate
Sarcoma
bone and soft tissue
Such as osteosarcoma
Leukemia
begins in blood-forming tissue of the bone marrow
Lymphoma
begins in lymphocytes (T or B cells)
Build up in lymph nodes and lymph vessles
Absolute risk
How many people get “x” in a certain period
If 4 people out of a group of 100,000 get “x” then risk is 4 in 100,000
Relative risk
% of people in exposed group with dz/ % of people in unexposed group with dz
RR>1: trait linked to ⬆️;
RR =1 trait not linked to dz;
RR < 1 trait linked to ⬇️ in dz
Tumor staging
TNM;
T: size/extent of primary tumor
TX: tumor cannot be measured.
T0: tumor cannot be found.
T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the more it has grown into nearby tissues.
N: # of nearby lymph nodes which are +
NX: cancer in nearby lymph nodes cannot be measured.
N0: no cancer in nearby lymph nodes.
N1, N2, N3: number and location of lymph nodes that contain cancer. The higher the number after the N, the more lymph nodes that contain cancer.
M: is there metastasis
MX:cannot be measured.
M0: has not spread to other parts of the body.
M1: has spread to other parts of the body.
Tumor staging is done when?
at diagnosis and not restaged
Localized staging
limited to place where it started; no sign of spread
in situ staging
abnormal cells are present but have not spread to nearby tissue (can be resected)
Regional staging
has spread to nearby lymph nodes, tissues, or organs
Distant staging
spread to distant parts of body (metastasized)
Unknown staging
not enough information to figure out the stage
Cancer prognosis
Tools lack usefulness
Functional status and laboratory values more important than type
median survival of 6 months or less
pt in bed > 1/2 the day
serum calcium > 11.2 mg/dl
DVT/PE
2 or more brain metastases
SC compression w/ limited mobility
maligant pericardial effusion
Hetapic, bone, or adrenal metastases
Recurrence of dz after chemo
serum albumin < 3.5 mg/dl or wt loss > 10% in 6 month
Cancer metastasis
Breast, lung, kidney, and prostate
Frequently radiate to bone (painful)
Osteolytic, osteoblastic or both lesions
Hormonal therapy often helpful
Radiotherapy/chemotherapy
NSAID +/- opioids
Vertebroplasty?
Cancer pain originates______
invasion of tumor into tissues innervated by afferent neurons; Pleura, peritoneum
directly invades nerve plexus
Does the cancer or the treatment cause pain?
Most pain is due to cancer itself not treatment
WHO “Cancer Pain Stepladder” (4)
Prompt administration
On schedule; not prn
Add antianxiety drugs as necessary
80-90% effective
Nerve blocks for cancer pain are done when?
Usually used when pharmacologic treatment fails
Either persistent pain or excessive side effects
Reason for Nerve blocks for cancer pain
Decreases opioid usage but pain relief usually incomplete
Mostly used with short life-expectancy
Celiac plexus block is used for what cancers? (3)
Unresectable pancreatic cancer, hepatic or gastric cancer
Celiac plexus block MOA and SE
Neurolysis sympathetic fibers of T5-T12 and parasympathetic celiac plexus fibers
lysis is done with Alcohol/ destroys nerve fibers->pain relief 3-6 months
Side effects of blocking celiac plexus: diarrhea and hypotension
Intercostal nerve block is done for what cancer?
For rib metastasis
What block can be done for a pelvic tumor?
Lumbar sympathetic ganglion
Principle benefit of Continuous catheter techniques (epidural or intrathecal) (2)
Decrease in systemic side effects
Technique and equipment ubiquitous
Drawbacks from continuous epidurals/intrathecal
Limited duration of therapy d/t migration, granulomas, lack of homogenous drug distribution, infection rates
No RCT’s…
Chemotherapy does what? (4)
Kill cancer cells
Shrink tumors
Prepare patients for bone marrow transplant
Control overactive immune disease…lupus, RA
Chemotherapy targets what?
Target cells in different phases of cell cycle
Alkylating agents
Damage cell DNA-> Unable to reproduce
Work in all phases of cell cycle
Treat many types of cancers
SE; Dose dependent leukemia 5-10 years after treatment
Alkylating agents that can cross the BBB
Nitrosoureas
Ex: “platins”…cisplatin
Antimetabolites MOA
Interfere with DNA and RNA
Act as substitute for normal building blocks
Antimetabolites are used to treat what?
Commonly treat breast, ovary, intestines, leukemias
methotrexate, 5-FU is what type of chemo drug?
Antimetabolites
Anti-tumor antibiotics MOA
Interfere with enzymes copying DNA
Widely used for large variety of cancers
Anti-tumor antibiotics SE
Permanently damage heart in large doses
Have life-time dose limits
“rubicins” Doxorubicin; bleomycin, Mitomycin-C are examples of what type of chemo drug
Anti-tumor antibiotics
Topoisomerase inhibitors treat what?
Treat leukemias, lung, ovarian, GI, colorectal, pancreatic
Plant alkaloids are what type of chemo drug? and MOA
Topoisomerase inhibitors
Plant alkaloids; Prevent strands of DNA from being separated to copy
Topoisomerase inhibitors SE
Increase risk of a second cancer
Mitotic inhibitors MOA
Damage cells in all phases by preventing protein synthesis
Treat many types of cancers
Mitotic inhibitors SE
May cause peripheral neuropathy
Targeted therapy
Drugs that use specific proteins or receptors on cancer cells
Normal cells are not affected
Hormone therapy
Prevent body from making hormone
Slow growth of hormonal tumors…breast, prostate, uterine
Immunotherapy
Drugs that boost immune system
Better recognize cancer cells
Normal cells most likely to be damaged during chemotherapy
Blood forming in bone marrow
Hair follicles
Cells in mouth, digestive tract, and reproductive systems
Side effect of aprepitant (neurokinin-1 antagonist)
May inhibit hormonal contraceptives x 28 days
Marijuana and n/V with chemotherapy
Depressed CNS vomiting center
More effective than phenothiazines (prochlorperazine or chlorpromazine)
Decreases anesthetic requirements 15-30%
What to consider with peripheral vasculature in assessment
6x increase in embolic events
? Evidence current of DVTs
Head/neck cancers assessment
Hypothyroidism(Thyroid function test)
Carotid artery disease (Auscultate for bruits, carotid doppler studies)
Airway management issues
Chest wall or left breast
assessment related to radiation
pericarditis, conduction abnormalities, cardiomyopathy, valvular abnormalities
EKG and the stress test and/or echo as needed
Lungs, breast or mediastinal cancer/ radiation consider what complication?
radiation pneumonitis
assess Oxygen sats, CXR, PFT’s if needed
Adriamycin SE
Cardiomyopathy
Bleomycin SE
Pulmonary toxicity
keep them close to 21% because the oxygen makes them toxic
Cisplatin or vincristine SE
Peripheral neuropathy
Lab abnormalitiesr/t chemotherapy
Preoperative anemia, neutropenia, and/or thrombocytopenia
hypercalcemia
Adrenal insufficiency
Resection is a risk factor for what cancer concern?
Tumor recurrence
Tumor cells can spread through circulation
Minimal residual disease can remain behind
Localized spread can occur via the lymphatic system
Causes of immunosuppression
Inflammatory response???
Surgical stress???
Effects of anesthesia ???
Administration of opioids???
Inflammation from tissue trauma and physiological stress
Occurs because of the Activate overexpression of COX2 genes
Catalyzes prostaglandins and thromboxane from arachidonic acid
Elevated levels promote cell survival and growth of cancer cells
May suppress NK cells
Beta adrenergic receptors signaled by fight or flight response
causes…….
receptors at sites of tumor growth and metastasis
Upregulate biological activity of cancer cell types
Driven by nerve fiber delivery of NE not blood delivery
Inflammation/ stress response can last for _____
weeks
meningionma
cancer in the tissue covering brain and spinal cord
Leading cause of cancer deaths in both genders
Lung cancer
Causes of lung cancer
Tobacco smoke…90%
3 decade lag time
Asbestos
Radon gas (uranium decay)
Types of lung cancer
Small-cell (SCLC)
Non-small-cell (NSCLC)…..75-80%
-Squamous
-Adenocarcinoma
-Large-cell
Less common carcinoid, mesotheliomas
Small cell lung cancer originates where
Neuroendocrine in origin
Small cell lung cancer features
Considered metastatic on presentation
Medical disease
Staging is only ”limited” or “extensive”
Small cell lung cancer treatment
Chemotherapy
Radiation of tumor and cranium (prophylactically)
Always recurs and is resistant to further treatment
Side effects of SCLC
Hyponatremia (SIADH )
Hypercortisolism (Cushings disease)
Lambert-Eaton syndrome
Lambert-Eaton syndrome
Called myasthenic syndrome
Proximal lower limb weakness/fatigability
Similar to myasthenia gravis but
Improves with exercise
Doesn’t improve with acetylcholinesterase inhibitors
Extremely sensitive to non-depolarizing NMBDs
Carcinoid tumors features (3)
Neuroendocrine tumors
Mostly benign
5 year survival > 90%
Carcinoid syndrome (usually caused by tumors of gut not lung)
Serotonin, histamine, tachykinins, kallikrein, prostaglandins.
Hemodynamic collapse…unresponsive to vasopressors
Coronary artery spasm
Treated with antagonists…octreotide/somatostatin
Inhibits tumor growth, angiogenesis, and secretion of hormones from tumor
Non-small-cell (NSCLC) features
5 year survival
10% without surgery
40% with surgery
Squamous cell grow _____ but_____
Grow to a large size but metastasize late
Squamous cell Symptoms related to _____
mass effect;
Hemoptysis
Obstructive pneumonia
Superior vena cava syndrome
Endobronchial tumor
Most common type of lung cancer
metastasize early
Brain, bone, liver, adrenals
Chest wall, diaphragm, pericardium
Adenocarcinoma often secretes______ causing …….
Often secrete growth hormone and ACTH
Insulin resistance…to diabetes
Dyslipidemia
Moon facies
Buffalo hump
Delayed wound healing
Avascular necrosis of the femoral head
Osteoporosis
Least common of NSCLC’s
Large-cell
Large-cell lung cancer features
Metastasize rapidly
Large cavitating tumors
Assessment of patients with lung cancer
Mass effect
Metabolic abnormalities
Metastases
Medications
Preopconsiderations for cancer pts
Care with sedation (ease off)
Antisialogogue
SCIP antibiotics
Assess difficulty of lung isolation: CXR/CT
Assess risk of hypoxemia during 1-lung ventilation
Factors Predicting 1-lung desaturation (3)
- High % of ventilation or perfusion to the operative lung on preop V/Q scan
- Poor PaO2 during 2-lung ventilation
- Right-sided thoracotomy
ppoFEV1 %
PPOFEV1 % = Preoperative FEV1% x (1-%functional lung tissue removed/100)
Post thoracotomy/thoracoscopy analgesia
Epidural
Paravertebral blocks
NSAIDS
Opioids
lowers ppoFEV1 if supressed or can be higher if they are pain free
indications for paravertebral block
Fractured ribs
Benign/malignant neuralgia
Lung contusions
Major surgeries
Contraindications for paravertebral blocks
Infection at site
Empyema
Tumor in the paravertebral space
Chest deformities (kyphoscoliosis)
Paravertebral blocks MOA
Block spinal nerves as they exist intervertebral foramen
Lack fascia…more sensitive to LA
Single shot covers 4-6 dermatomes
Paravertebral block for sternotomy, thoracotomy, and abd procedures
Level of block
T4 for sternotomy
T6 for thoracotomy
T10 for abdominal procedures
Intercostal nerve block MOA
Innervates musculature of chest and abdominal wall
Requires blockade of 2 dermatomes above and 2 dermatomes below incision
Indications for intercostal nerve block
Thorax and upper abdomen surgery
Mastectomy
Disadvantages of Intercostal nerve block
Disadvantages
Risk of pneumothorax
LA toxicity with multiple levels of blockade
How to do a Intercostal nerve block
Identify spinous process, tip of scapula, angle of rib
