Mucositis is a painful inflammation and ulceration of the
mucous membranes of the digestive tract. Oral lesions begin as
mucosal whitening followed by the development of erythema and
tissue friability. Oral mucositis is a relatively common adverse
effect of high-dose chemotherapy and radiation to the head and
neck. Mucositis can also occur in the context of hematopoietic stem
cell transplantation.
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Chemotherapeutic drugs associated with mucositis include:
-anthracyclines -taxanes -platinum-based compounds -methotrexate -
fluorouracil. Mucositis associated with chemotherapy often begins
during the first week of treatment and typically resolves after
treatment is terminated.
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Mucositis associated with radiation therapy usually has a more
delayed onset. Patients with mucositis are at risk of infection
from spread of oral bacteria. Narcotics are frequently required to
achieve adequate analgesia. In its most severe form, pseudomembrane
formation, edema, and bleeding may cause airway compromise or risk
of aspiration.
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Radiation to the head and neck can result in permanent tissue
fibrosis that may limit mouth opening and neck and tongue mobility.
Airway fibrosis and tracheal stenosis may result in difficulty in
ventilation and intubation that is not recognized on physical
examination.
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Preoperative evaluation of patients with cancer includes
consideration of the pathophysiologic effects of the disease and
recognition of the potential adverse effects of cancer treatments
(Table 23-4).
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In addition, the patient's underlying medical comorbidities
must not be overlooked. Correction of nutrient deficiencies,
electrolyte abnormalities, anemia, and coagulopathies may be needed
preoperatively.
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In most cases, laboratory evaluation should include: -complete
blood count -coagulation profile - serum electrolyte concentrations
-transaminase levels.
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Chest radiography, echocardiography, pulmonary function
evaluation, and other specialized testing should be used if
clinical suspicion warrants.
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chemotherapeutic drugs have the potential to impair wound
healing, especially the growth factor and angiogenesis inhibitors.
It has been suggested that surgery be delayed for 4 to 8 weeks
after treatment with bevacizumab because of an increased risk of
bleeding and postoperative wound complications.
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Potential pulmonary or cardiac toxicity is a consideration in
patients being treated with chemotherapeutic drugs known to be
associated with these complications. The myocardialdepressant
effects of anesthesia can unmask cardiac dysfunction related to
cardiotoxic chemotherapeutic drugs such as doxorubicin. Therefore,
when major surgery is planned, preoperative echocardiography may be
indicated. Since several chemotherapeutic agents can cause
electrocardiographic abnormalities such as QT prolongation, a
baseline electrocardiogram should be reviewed.
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A preoperative history of drug-induced pulmonary fibrosis
(dyspnea, nonproductive cough) or congestive heart failure will
influence the subsequent management of anesthesia. In patients
treated with bleomycin, it may be helpful to perform arterial blood
gas monitoring in addition to oximetry and to carefully titrate
intravascular fluid replacement, since these patients are at risk
of developing interstitial pulmonary edema, presumably because of
impaired lymphatic drainage in the lung.
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Bleomycin-associated pulmonary injury may be exacerbated by
high oxygen concentrations; therefore, it is prudent to adjust the
delivered oxygen concentration to the minimum that provides
adequate oxygen saturation. Nitrous oxide may augment the toxicity
of methotrexate, so it is best avoided.
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The presence of hepatic or renal dysfunction should influence
the choice and dose of anesthetic drugs and muscle relaxants. the
possibility of a prolonged response to succinylcholine is a
consideration in patients being treated with alkylating
chemotherapeutic drugs like cyclophosphamide. The presence of
paraneoplastic syndromes such as myasthenia gravis and
Eaton-Lambert syndrome may also affect the patient's response to
muscle relaxants.
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Attention to aseptic technique is important, because
immunosuppression occurs with most chemotherapeutic agents and is
exacerbated by malnutrition. Immunosuppression produced by:
1-anesthesia, 2 -surgical stress, 3- blood transfusion during the
perioperative period could have deleterious effects on the
patient's subsequent response to his or her cancer.
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Adrenal suppression may be present in patients who are being
treated with steroids. Those who have been receiving more than 20
mg of prednisone (or its equivalent) per day for longer than 3
weeks are considered most at risk. Recovery of the hypothalamic-
pituitary- adrenal axis may take up to a year. A typical steroid
replacement regimen is hydrocortisone 100 mg IV administered at
induction of anesthesia followed by 100 mg IV every 8 hours for the
first 24 hours after surgery.
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Intubation in the presence of oral mucositis may cause
bleeding. Patients with cancers of the head, neck, and anterior
mediastinum may exhibit airway compromise. Patients with a history
of radiation exposure may have airway deformities that are
difficult to recognize on physical examination.
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Recent evidence suggests that anesthetics and analgesics have
immunomodulatory properties. Intravenous opioids tend to blunt
natural killer cell activity, producing an immunosuppressive effect
that supports the proliferation of tumor cells. The use of
neuraxial anesthesia may preserve the host's intrinsic anticancer
defenses better than general anesthesia. However, coagulopathies
may prevent the use of these techniques in some cancer patients.
Peripheral nerve blocks may be utilized, but baseline peripheral
neuropathies related to chemotherapeutic drugs such as vincristine
and cisplatin should be well documented.
Slide 21
Postoperative care must include adequate attention to pain
management. Many cancer patients have been treated for pain related
to their underlying diagnosis. Therefore, narcotic dosing must be
adjusted to account for possible drug tolerance. Prophylaxis
against infection and thromboembolism must also be considered.