tracheal deviation or compression SOB difficulty breathing (sign of airway obstruction) dysphagia Preop airway assessment, cervical ROM, cervical X-ray, ENT consult

Lecture 2: Preoperative Assessment of the Patient with Cancer AL Flashcards by William Leake

TEST BANK ?s

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Treatments:

surgery
chemotherapy
radiation therapy

Toxicities and adverse effects that have the potential to affect nearly every ?

Treatments:

surgery
chemotherapy
radiation therapy

Toxicities and adverse effects that have the potential to affect nearly every organ system.

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Adverse effects: Bleomycin***

Pulm. HTN, pulm. fibrosis

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Adverse effects: Cisplatin***

Dysrhythmias
mg wasting
mucositis
ototoxicity
p. neuropathy 
SIADH 
renal tubular necrosis 
thromboembolism

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Adverse effects: Cyclophosphamide (Cytoxan)***

Encephalopathy/delirium
hemorrhagic cystitis
myelosuppression
pericarditis
pericardial effusion
SIADH
pulm. fibrosis

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Adverse effects: Doxorubicin (Adriamycin)***

Cardiomyopathy

myelosuppression

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Adverse effects: Fluorouracil***

Acute cerebellar ataxia
ischemic and nonischemic EKG changes
Chest pain
gastritis
myelosuppression

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Adverse effects: Methotrexate***

Encephalopathy
hepatic dysfunction
mucositis
platelet dysfunction
hypersensitivity pneumonitis
renal failure
myelosuppression

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Adverse effects: Tamoxifen***

Thromboembolism

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Adverse effects: Vincristine***

autonomic dysfunction
myocardial ischemia 
p. neuropathy
bronchospasm
SIADH

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Adverse effects: Radiation therapy

**Review Table 28.3, Slide 10!

Sinusoidal obstruction syndrome -> severe liver failure

Review Table 28.3, Slide 10!

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Preoperative Assessment: History and comorbidities

malignancy in the head or neck ->?

mediastinal masses obstructing great vessels
• dyspnea, dysphagia, stridor, wheezing, coughing→?
• compression of SVC→?

Preop testing: a lot of tests

Anesthestic concerns:

Preoperative Assessment: History and comorbidities

malignancy in the head or neck
• airway exam and possible need for tracheostomy
• Recurrent laryngeal n. damage

mediastinal masses obstructing great vessels
• dyspnea, dysphagia, stridor, wheezing, coughing→ recumbent pos.
• compression of SVC→JVD, facial, chest, neck, upper ext edema

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Airway Assessment:

tracheal deviation or compression
SOB
difficulty breathing (sign of airway obstruction)
dysphagia
Preop airway assessment, cervical ROM, cervical X-ray, ENT consult

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***SVC Comp Syndrome + Tracheal Comp = ?

***SVC Comp Syndrome + Tracheal Comp = Superior Mediastinal Syndrome

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Airway: radiation to head and neck→ ?

radiation to head and neck→ permanent tissue fibrosis 
• carotid artery ds 
• hypothyroidism 
• difficult ventilation 
• difficult intubation
*May not be recognized on physical exam

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Slide 16: just read through

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Preoperative Assessment: Functional status
chemo and radiation take a toll on patient
• Assess __________ status→ ________ tolerance

Preoperative Assessment: Functional status
chemo and radiation take a toll on patient
• Assess functional status→ exercise tolerance

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Preoperative Assessment: Geriatrics
Greater comorbidities, frailty, polypharmacy
• risk of ?
• “Chemobrain” = ?

Preoperative Assessment: Geriatrics
Greater comorbidities, frailty, polypharmacy
• risk of delirium
• “Chemobrain”—chemo-induced cognitive dysfunction
- doc preop!

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Preoperative Assessment: Education and prevention 
management of ? 
exercise routine \_\_\_\_ to surgery
• improves ? 
• “prehabilitation” 
• tobacco cessation

Preoperative Assessment: Education and prevention
management of comorbidities
exercise routine prior to surgery
• improves surgical recovery and improves overall survivorship
• “prehabilitation”
• tobacco cessation

Preoperative Assessment: Previous Cancer treatments
Prior cancer treatment and dates
• long-term _________
• acute _________

Preoperative Assessment: Previous Cancer treatments
Prior cancer treatment and dates
• long-term side effects
• acute side effects

Preoperative Assessment: CV system
• HR, pulse, and carotid arteries

If bruits are present→___________
• if severe stenosis and large intraop fluid shifts are expected, then ___________ is considered.
• mild stenosis→ _______________ therapy

Significant fatigue and loss of functional status
• echo ordered and results are WNL? ___________
• thoughts? ___________
• Cardiac stress testing might be considered (?)
• Lab________

hold breath x 15 sec
revascularization
pharmacological
does NOT mean no concerns
deconditioning
YES
BNP (HF)

Cardiovascular System: Doxorubicin (Adriamycin) ***
• cardiotoxicity may be acute or chronic:

radiation (mediastinal)→?
periodic ?

QT prolongation
cardiomyopathy
dysrhythmias
ischemia-related EKG changes
HTN (monoclonal antibodies & tyrosine kinase inhibitors) -> Difficult to manage→ ACEIs and CCBs

accelerated CAD, valvular fibrosis, conduction abnormalities

echocardiography

Respiratory System*
• Drug? 
• pulmonary toxicity 
- pneumonia 
- pulmonary fibrosis

Tests?

• avoidance of exposure to intraop high conc of ?**

preop admin of?

Respiratory System*
• Bleomycin 
• pulmonary toxicity 
- pneumonia 
- pulmonary fibrosis

baseline and serial pulmonary function testing
chest radiography
pleural effusion ?

• avoidance of exposure to intraop high conc of O2**

preop corticosteroids

Respiratory
• Pulmonary System 
- Adenocarcinoma (30-50%)→ history of ? 
- Large cell – ? 
- Small cell -\_\_\_\_\_\_\_\_\_\_ weakness? 
- Pain in ?
- Do you have frequent .......?
- Do you have X, Y, Z syndromes?

• Pulmonary System

Adenocarcinoma (30-50%)→ history of blood clots?
Large cell –gynecomastia?
Small cell -muscle weakness?
Pain in hands, fingers, knees, ankles?
Do you have frequent lung infections or pleural effusions?
Paraneoplastic syndrome, Eaton Lambert Syndrome, Myasthenia gravis?

Review Table 28.4 Slide 26!

Renal System cisplatin*, high-dose methotrexate • ______ insuff → usually resolves with ________ of tx ``` cyclophosphamide* • _____ • ________________ • Medication concerns:________________ • Renal labs? ``` • tumor cell lysis?

Renal System cisplatin*, high-dose methotrexate • renal insuff → usually resolves with cessation of tx ``` cyclophosphamide* • SIADH • inhibit pseudocholinesterase • Medication concerns: Mivacurium • Renal labs: BUN, Cr, GFR ``` • tumor cell lysis - radiation & chemo -> increase uric acid, Phos, K

``` Hematologic System • ____suppression • nadir? • CA produces ______________ state - _______________ events are increased six-fold in pts w/CA ```

``` Hematologic System • myelosuppression • nadir: RBCs, WBCs, Plts • CA produces hypercoagulable state • thromboembolic events are increased six-fold in pts w/CA ```

Hematologic—preoperative questions?

``` Bruising/bleeding Clots (Hx) Transfusions/anemia Chemo (last) Prone to infections? ```

Neurological System • __________—virtually all patients experience paresthesias - peripheral neuropathy - encephalopathy * ______________-induced neuromuscular toxicity (_____________ 60-100mg/day) * radiation + methotrexate→?

Neurological System • vincristine—virtually all patients experience paresthesias - peripheral neuropathy - encephalopathy * corticosteroid-induced neuromuscular toxicity (prednisone 60-100mg/day) * radiation + methotrexate→ irreversible dementia

Neurological—preoperative questions?

``` Numb/tingling MS agents on in the past Muscle weakness EL or MG? ```

GI System Almost all ______ and _______ produce GI SEs: ? ___________, __________, __________ • *nutritional supplementation via enteral or parenteral routes improves surgical outcomes radiation→ ? • *? syndrome • *reactivation of ?

GI System Almost all chemo and radiation produce GI SEs. • mucositis • n/v • diarrhea e’lyte 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

GI—preoperative questions?

nutritional status have you been on hyperalimentation? have you ever had a central line? difficulty swallowing

Endocrine System *Steroids are frequently used • Addition to chemotherapy regimen→ ? • Might unmask undiagnosed diabetes.....Lab? • Might make known ________more difficult to treat • Increases risk of ________ insufficiency (suppression of ?) Radiation to neck head might alter thyroid function • Concerns?

*Steroids are frequently used • Addition to chemotherapy regimen→ -reduce inflammation -reduce n/v -boost appetite • Might unmask undiagnosed diabetes.....Lab? A1C • Might make known diabetes more difficult to treat • Increases risk of adrenal insufficiency (suppression of hypothalamic-pituitary-adrenal axis) Radiation to neck head might alter thyroid function • Concerns? Prior steroid use?

Endocrine—preoperative questions?

Have you been taking steroids? | Do you have a hx of diabetes?

Glance over table 28.5 Slide 37 | Preanesthetic evaluation of the CA patient

Slide 38: multi hit hypothesis for cancer deconditioning

Preoperative | Correction of?

* Nutrient deficiencies * Electrolyte abnormalities * Anemia * Coagulopathies * Steroid replacement

``` Cancer Laboratory & Tests: review •Hematocrit -> Anemia •Platelet Count -> Thrombocytopenia •WBC count •Neutropenia •Liver function •PT/ PTT/ INR (coag studies) •BNP •CXR •12-lead ECG •Renal function-BUN/Creatinine clearance •Electrolytes -Ca++hypercalcemia due to bone mets and osteolytic activity. -K+, Na++, Ca++, Mg •Blood glucose •ABGs •ECHO •PFTs ```

``` Cancer Laboratory & Tests •Hematocrit -> Anemia •Platelet Count -> Thrombocytopenia •WBC count •Neutropenia •Liver function •PT/ PTT/ INR (coag studies) •BNP •CXR •12-lead ECG •Renal function-BUN/Creatinine clearance •Electrolytes -Ca++hypercalcemia due to bone mets and osteolytic activity. -K+, Na++, Ca++, Mg •Blood glucose •ABGs •ECHO •PFTs ```

Cancer Laboratory & Tests: review ❑Chest Xray: tracheal deviation or compression, masses, aortic aneurysm, fractures (ribs, clavicle, vertebrae), cardiomegaly, pulmonary edema, pneumonia, atelectasis, chronic disease

Cancer Laboratory & Tests: ❑Chest Xray: tracheal deviation or compression, masses, aortic aneurysm, fractures (ribs, clavicle, vertebrae), cardiomegaly, pulmonary edema, pneumonia, atelectasis, chronic disease

Cancer Laboratory & Tests: review ❑EKG-Abnormalities that will alter anesthetic plan include: Afib, Aflutter, Heart Blocks, ST-T segment changes indicating ischemia, infarct or recent PE, PV & PACs, LVH, RVH, WPW, prolonged QTI or shortened PRI, peaked T waves

Cancer Laboratory & Tests: ❑EKG-Abnormalities that will alter anesthetic plan include: Afib, Aflutter, Heart Blocks, ST-T segment changes indicating ischemia, infarct or recent PE, PV & PACs, LVH, RVH, WPW, prolonged QTI or shortened PRI, peaked T waves

Oncologic Emergencies | • spinal cord compression->

Oncologic Emergencies | • spinal cord compression—urinary or bowel incontinence, peripheral neuropathies, gait disturbances

Oncologic Emergencies | • Cardiac tamponade—>

Oncologic Emergencies | • Cardiac tamponade—muffled heart tones, elevated JVD, distended neck veins, progressive dyspnea

Oncologic Emergencies | • Neutropenia sepsis—>

Oncologic Emergencies | • Neutropenia sepsis—may present with low-grade fever or none, cough, arthralgia

Oncologic Emergencies | • CNS metastasis—>

Oncologic Emergencies | • CNS metastasis—headaches, visual disturbances, balance and gait disturbances, confusion, n/v

Oncologic Emergencies | • Tumor lysis syndrome—>

Oncologic Emergencies • Tumor lysis syndrome—elevated uric acid, K+, & phos levels. Most often seen 12-72 hours post chemo tx for hematologic malignancy

Oncologic Emergencies | • SVC syndrome—>

Oncologic Emergencies | • SVC syndrome—obstruction of SVC (swelling of hands, neck face, dyspnea, cough)