Cancer Assessment Flashcards
Radiation effects, skin: acute and chronic
Acute: erythema, rash, hair loss
Chronic: fibrosis, sclerosis, telangiectasias
Radiation effects, GI: acute and chronic
acute: malnutrition, mucositis, N/V
chronic: adhesions, fistulas, strictures
Radiation effects, cardiac: acute and chronic
acute: none
chronic: conduction defects, pericardial effusion, pericardial fibrosis, pericarditis
Radiation effects, resp: acute and chronic
acute: none
chronic: airway fibrosis, pulmonary fibrosis, pneumonitis, tracheal stenosis
Radiation effects, renal: acute and chronic
acute: glomerulonephritis
chronic: glomerulosclerosis
Radiation effects, hepatic: acute and chronic
acute: sinusoidal obstruction sydrome
chronic: none
Radiation effects, endocrine: acute and chronic
acute: none
chronic: hypothyroidism, panyhypopituitarism
Radiation effects, hematologic: acute and chronic
acute: bone marrow suppression
chronic: coagulation necrosis
common chemo toxicities: cisplatin
alkylating agent
acoustic n. injury + nephrotoxicity
common chemo toxicities: vincristine & vinblastine
tubulin binding drug
peripheral neuropathy
common chemo toxicities: bleomycin
antitumor antibiotic
pulmonary fibrosis (keep fiO2 < or = 30%)
common chemo toxicities: doxorubicin
antitumor antibiotic
cardiotoxic
common chemo toxicities: 5 - fluorouracil
antimetabolite
bone marrow suppression
common chemo toxicities: methotrexate
anti metabolite
bone marrow suppression
Preoperative Airway Assessment: consdierations
- malignancy in head or neck
- mediastinal masses
- tracheal deviation or compression
- SOB
- difficulty breathing (sign of airway obstruction)
- dysphagia
- cervical ROM
- cervical xray
- ENT consult
Mediastinal masses can obstruct which structures and cause which syndrome?
- aorta, PA, PV, SVC
- heart trachea, bronchi
can cause SVC syndrome!
S/S of SVC syndrome and associated airway plan
Signs: JVD, facial, neck, chest edema, inc ICP, airway compromise
Symptoms: dysphagia, dyspnea, wheezing, coughing (especially) when recumbent
AW Plan: consider awake fiberoptic intubation –> (intubate patient with all airway reflexes and muscle tone intact)
Radiation to head and neck: airway assessment considerations not recognized on physical exam.
- carotid artery dissection - listen for bruit (may need to order a doppler study)
- hypothyroid (order thyroid function tests)
- difficult ventilation/intubation related to permanent tissue fibrosis
Best way to assess functional status
EXERCISE TOLERANCE
chemo and radiation take a toll on functional reserve
CV assessment and considerations
doxorubicin (adriamycin)
cardiotoxicity may be acute or chronic
- QT prolongation
- cariomyopathy
- dysrhythmias
- ischemia related EKG changes
- HTN
radiation (mediastinal) –> accelerated CAD, valvular fibrosis, conduction abnormalities
periodic echo
CV pre op questions
Do you have cardiomyopathy (damage to your heart)?
Do you experience arrhythmias (irregular heart beats)?
Can you lie supine or are you symptomatic when supine (do you have trouble breathing or feel uncomfortable when laying flat)?
Respiratory assessment and considerations
Bleomycin
pulm toxicity – PNA, pulmonary fibrosis
baseline and serial PFT
chest radiography
AVOIDANCE OF EXPOSURE TO INTRAOP HIGH CONC OF O2
pre op corticosteroids
Respiratory pre op questions
Do you have frequent lung infections or pleural effusions?
Adeoncarcinoma (30-50%) –> history of blood clots, osteoarthritis?
Small cell - muscle weakness? worry about them being highly sensitive to NMB!
EXERCISE TOLERANCE?
Inhalers?
Home O2?
Renal assessment and considerations
CISPLATIN, high dose methotrexate
–renal insufficiency - usually resolves with cessation of TX
CYCLOPHOSPHAMIDE
- -SIADH
- -Implications: body retains water –> hyponatremia
- -Labs: metabolic panel, electrolytes
tumor cell lysis –> inc uric acid (renal tubule crystals), phosphate, and K+
–HYDRATION
Hematologic assessment and consideratoins
MYELOSUPPRESSION
- dec RBCs (O2 carrying capacity)
- dec WBCs (inc risk of infection)
- dec platelets (ability to clot)
-Nadir (lowest point) - (usually 7-14 days after last chemo treatment)
CA PRODUCES HYPERCOAGULABLE STATE
- thromboembolic events are increased 6 fold in pts with CA
- esp primary brain tumors, ovarian adenocarcinoma, pancreatic CA, colon CA, gastric, CA, lung CA, prostate CA, and kidney
Hematologic pre operative questions
Do you have hx of anemia?
Have you ever been told you have low blood counts?
Are you dizzy when you stand up? (also considers orthostatic hypotension, exercise tolerance)
History of a blood transfusion?
Are you prone to infections?
Thrombocytopenia
Do you bruise easily?
Do you get nose bleeds frequently?
Have you been noticing bleeding when you brush your teeth?
Neurological system assessment and considerations
VINCRISTINE - virtually all patients experience paresthesias, peripheral neuropathy, encephalopathy
important to document pre existing status of neuropathies prior to anesthesia, consider appropriate positioning as to not worsen neuropathies
corticosteroid-induced neuromuscular toxicity (prednisone 60-10mg/day)
- -do you have difficulty getting out of a chair?
- -could cause some weakness of respiratory muslces
- -will likely need stress dose of steroids
radiation + methotrexate –> irreversible dementia
Neurological pre op questions
Do you have numbness and tingling?
Do you pain? What do you currently use for pain?
Hx of stroke? Deficits?
Recent changes to memory? - want to document prior to anes.
Cognitive side effects? - want to document prior to anes.
Are you on steroids?
Pearl to remember when compiling all preoperative assessment questions.
MAKE SURE YOU’RE ASKING RELEVANT QUESTIONS, and not just asking questions just to ask.
Will the answer to their question affect your anesthetic plan or not?
GI system assessment and considerations
Almost all chemo and radiation produce GI SEs
- mucositis
- n/v
- diarrhea
Electrolyte imbalances, dehydration, malnutrition
—nutritional supplementation via enteral or parenteral routes improves surgical outcomes
Radiation –> stenotic lesions throughout the GI tract
- sinusoidal obstruction syndrome
- reactivation of Hep B
- –s/s of jaundice (eyes and skin), malaise, n/v?
GI pre operative questions
Recent weight loss or weight gain?
N/V/D? What works for them?
If patient tells you they have been nauseous that day or threw up that day —> consider RSI, more aggressive antiemetic plan, fluid/electrolyte balance
How has your PO intake been? (will you need to be more aggressive with IV fluids?)
Endocrine assessment and consierations
Steroids are frequently used
–addition to chemotherapy regimen (reduce inflammation, reduce n/v, boost appetite)
- -might unmask undiagnosed diabetes
- –lab: blood glucose, A1C
–increases risk of adrenal insufficiency (suppression of hypothalamic - pituitary -adrenal axis) —> inadequate cortisol production or stress hormone response—> may need to supplement
Radiation to head/neck might alter thyroid function
- Concerns about hypothyroid during sx?
- —hypotension, poor temp regulation, just might not respond as expected to stressors, asp risk - slower gastric emptying
Endocrine pre op questions
Hx of problems with thyroid? (recent weight gain, feeling sluggish, always the one in the room who says its too cold)
Hx of DM or high blood sugar levels?
Multiple hit hypothesis for cancer deconditioning
- chemotherapy
- radiation
- surgery
- cancer
- age, sarcopenia
- medical comorbidities
- sedentary lifestyle
- cancer fatigue
Preoperative considerations: important to ensure correction or optimization of?
- nutrient deficiencies
- electrolyte abnormalities
- anemia
- coagulopathies
- steroid replacement?
Breast cancer may metastasize to?
bone – be mindful of hypercalcemia
prostate cancer may metastasize to?
bone – be mindful of hypercalcemia
lung cancer (esp small cell) may metastasize to?
brain
also, be mindful of NMB with small cell lung CA, tend to be very sensitive (myasthenic syndrome)
colon cancer may metastasize to?
liver
Conditions that may warrant a chest xray
tracheal deviation or compression masses aortic aneurysm fractures (ribs, clavicle, vertebrae) cardiomegaly pulmonary edema PNA atelectasis chronic disease
Conditions that may warrant an EKG
abnormalities that will alter anesthetic plan include: a fib a flutter heart blocks ST - T segment changes indicating ischemia, infarct or recent PE PVCs, PACs LVH, RVH WPW prolonged QT or shortened PRI peaked T waves
Oncologic emergencies
- spinal cord compression
- cardiac tamponade
- neutropenia sepsis
- CNS metastasis
- tumor lysis syndrome
- SVC syndrome
Breast cancer surgery: pre op considerations
- poor IV access
- at risk for lymphedema - AVOID IVS AND BP CUFF ON SURGICAL ARM
- check type of chemo for complications
Lung cancer surgery: pre op considerations
- associated CAD
- pulm insufficiency after lung tissue resection
- potential for massive blood loss during surgical resection –> adequate IV access, T&C, blood ready to go, appropriate tubing
- special equipment needed
pre op PFTs, DLCO, VO2 max, CXR, ABGs, O2 sat, cardiac stress testing, hbg/hct, T&C
Colon/GI cancer surgery: pre op considerations
may be aspiration risk - give pre op aspiration risk prophylaxis, but NO REGLAN
may be dehydrated from colon prep and/or obstruction - pre op IV fluid!
may need T&S, T&C, depending on type of sx
prostate surgery: pre op considerations
robotic surgeries
special positioning (steep trendelenburg) - facial edema/consider conservative IV fluids
