Anesthetic Considerations in Ovarian Cancer Patients

Journal of Anaesthesia & Critical Care

Review Article

Anesthetic Considerations in Ovarian Cancer Patients: A Comprehensive review *

Uma Hariharan , Shagun Bhatia Shah Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India *

Corresponding Author: Dr Uma Hariharan BH 41, East Shalimar Bagh Delhi 110088, India.

Received Date: December 30, 2015; Accepted Date: January 18, 2016; Published Date: January 29, 2016 Citation: Hariharan U, Shah SB (2016) Anesthetic Considerations in Ovarian Cancer Patients: A Comprehensive review. Jol Aneth Criti Cre 2:10460. Copyright: © 2015 Hariharan U, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Ovarian carcinoma is one of the leading gynaecological cancers affecting an increasing number of women world-wide. The stage of presentation decides the mode of treatment: chemotherapy, cytoreductive surgery or a combination of both. Maintaining hemodynamic stability during massive fluid shifts, extensive monitoring, pre induction epidural catheter placement, prevention of hypothermia during cytoreductive surgery and hyperthermia during intraperitoneal chemotherapy phase, correction of metabolic or electrolyte derangements and adequate postoperative pain relief are the main perioperative goals. Anesthetic implications of cytoreductive surgery, chemotherapy (in particular heated intraperitoneal chemotherapy) and chemoport insertions are also reviewed in this article.

Keywords:

Ovarian

considerations;

carcinoma;

Cytoreductive

Anesthetic

developed for these patients in order to improve

surgery;

patient safety and quality of anesthetic care.

Chemotherapy; Cancer staging; HIPEC; Debulking.

Anesthesiologists should also be aware of the various stages of ovarian carcinoma and their

Introduction

purported line of treatment, so as to individualize

Ovarian cancer is the fifth most common cancer in females across Europe, with a steadily increasing incidence in women of child bearing age. Since surgery forms the backbone of management of ovarian carcinoma, anesthesiologists would more frequently encounter cases of ovarian cancer in the operation theatre and outside [1]. Special protocols for

the

overall

perioperative

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care

should

be

their anesthetic management. There is also evidence of association between cancer recurrence and the type of anesthesia chosen [2]. In addition to the perioperative

considerations

for

cytoreductive

surgery, anesthesiologists may also be involved in the care of patients undergoing various types of chemotherapy as part of the ovarian cancer management.

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Journal of Anaesthesia & Critical Care Current FIGO classification for ovarian carcinoma The

International

Federation

+ Retroperitoneal lymph nodes only III A1

III A1 (i) Metastasis 10mm

Gynecologists and Obstetricians in 2014 revised the staging classification of ovarian cancers, which has

Review Article

Microscopic, III A2

extrapelvic

(above

the

brim) peritoneal involvement ± Positive

important treatment implications [3]. The following

Retroperitoneal Lymph Nodes (RPLN)

table highlights the current staging for carcinoma

Macroscopic,

ovary

peritoneal

metastasis 2cm ± positive RPLN,

III C

IA I C1

extrapelvic,

metastasis, IV B

metastasis

to

extra-

abdominal organs (including inguinal

Extension to other pelvic intraperitoneal

lymph nodes and lymph nodes outside

tissues

of the abdominal cavity)

Stage II: Tumor involves 1 or both ovaries with

Stage IV: Distant metastasis excluding peritoneal

pelvic extension (below the pelvic brim) or primary

metastasis.

peritoneal cancer

The type of ovarian tumor also influences the line of

Stage

management and prognosis. Cancerous ovarian

Description

lesions arise from four important cell types:

Positive retroperitoneal lymph nodes III A

1. Surface Epithelium (Carcinomas): They are

and/or microscopic metastasis beyond the pelvis

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the most common and the most sinister type. These may present at an advanced stage for

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Review Article

treatment and pose various management

debulking is defined as an operation performed after

challenges.

a short course of induction chemotherapy, usually 2

2. Germ

Cell

Tumors

Dysgerminomas

grade cancer, there is also a possibility of retention

tumor): Most of them are benign and occur

of the contralateral ovary or the option of ovum

in younger women, with excellent prognosis.

preservation for future use. Fertility issues have to

tumors

Endodermal

or 3 cycles. In women of reproductive age with low

sinus

3. Stromal

and

(Teratoma,

(Granulosa-Theca

cell

be discussed with the patient preoperatively [7].

tumors and Sertoli-Leydig cell tumors): They

Chemotherapy can be given either before or after

are rare, hormone-secreting tumors arising

the definitive surgery. With the advent of HIPEC,

from the ovarian connective tissue.

hyperthermic chemotherapy can be delivered directly

4. Primary Peritoneal Carcinoma: They are

to the cancer cells of the peritoneal cavity after the

similar to ovarian epithelial tumors and arise

cytoreductive surgery [8]. This has significantly

from

(eg.

reduced cancer recurrence, but at the same time has

be

raised several patient safety concerns. Radiotherapy

associated with massive or recurrent ascites.

may be given for metastasis and is rarely given in

cells

lining

Psuedomyxoma

the

peritoneum

peritonei)

and

can

Treatment modalities for ovarian cancer

ovarian cancer patients. Advanced ovarian cancer has a poor prognosis. Anesthesiologists may be

Management of ovarian cancer depends on

involved not only in cytoreductive surgery and

the stage at presentation with a recent trend towards

HIPEC, but also in chronic pain management as well

curative rather than palliative approach [4]. Surgical

as

treatment forms the mainstay and includes staging

debulking surgery followed by platinum based

laparotomy,

salpingo-opherectomy,

chemotherapy forms the mainstay of advanced

hysterectomy, exploration for metastatic deposits,

ovarian cancer treatment. Recently, Neoadjuvant

extensive

sampling,

chemotherapy to reduce tumor bulk preoperatively

lymphadenectomy, peritonectomy, omentectomy and

followed by interval debulking surgery has been

surgical

bilateral

biopsies,

peritoneal

fluid

palliative

care

of

these

patients.

Primary

the

tumor.

In

some

developed in extensive stage IIIc or IV tumors [9].

splenectomy,

bowel

resection-

The postoperative complications and mortality rates

anastomosis, appendicectomy, cholecystectomy and

were found to be lower after interval debulking. An

partial liver resections may also be required for

important concern here is the inability to obtain the

adequate cytoreduction [5]. The aim is to remove as

goal of no residual tumor due to chemotherapy-

much tumor as possible. Recent surgical advances

induced fibrosis. It must be remembered that very

in the form of use of harmonic cautery, cryoablation

aggressive surgery in advanced ovarian cancer can

and robot-assisted radical surgery have improved

result in unnecessary morbidity and mortality without

patient outcomes. Optimal debulking surgery is

improving overall survival.

debulking

circumstances,

of

defined as no residual tumor load [6]. Interval

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Preoperative Considerations for Ovarian Laparotomy

diabetes mellitus, hypertension, coronary artery

The main preoperative concerns include the

derangements have to be adequately optimized.

disease, reactive airway disease and thyroid function

anesthetic implications of chemotherapeutic agents,

Ovarian

evaluation

the

propensity to develop Venous Thromboembolism

malignancy/metastasis, problems due to ascites,

(VTE). The Trousseau sign of malignancy or the

DVT (Deep Vein Thrombosis) prophylaxis and

Trousseau`s

discussions regarding options of perioperative pain

thrombophlebitis appearing in different locations over

management [10]. Pre-anesthetic evaluation must be

time [12]. They occur due to the hypercoagulable

extensive and thorough. All routine investigations

state associated with malignancies of the pancreas,

including complete hemogram, renal function tests,

lung, stomach and ovary.

liver

and

thromboprophylaxis and early ambulation must be

coagulation profile need to be done. Patient may

utilized in all cases. Patients should also be

have derangement in liver functions, especially low

counseled

protein and high enzyme levels, due to large ascites

analgesia during the pre-anesthetic visit

of

organ

function

system

tests,

serum

affliction

by

electrolytes

or metastatic deposits. Presence of ascites may cause reduction in functional residual capacity and

cancer

patients

have

syndrome

regarding

the

an

increased

involves

recurrent

Hence, mechanical

benefits

of

epidural

Intra-operative Anesthetic Management

pushing up of the diaphragm [11]. Pulmonary

Prioritization of anesthetic considerations

function derangement may also be due to concurrent

must be done to reduce patient morbidity and

pleural

mortality.

effusion.

preoperatively,

then

derangements. implications

If

patient there

is

may

Hypokalemia

with

the

on

diuretics

be

electrolyte

has

serious

intra-operative

use

of

Intra-operative

care

must

focus

on

managing the hemodynamics during fluid/blood loss; maintaining

oxygenation,

normothermia

and

normocarbia; supplementing analgesia with epidural

neuromuscular blocking agents. In patients who had

drugs;

undertaken neo-adjuvant chemotherapy, the toxic

metabolic/electrolyte

effects of the chemotherapeutic drugs must also be

thoracic epidural catheter insertion under local

considered. Apart from immunosuppression, these

anesthesia is encouraged to decrease the stress of

drugs can cause toxicity of various organ systems

anesthesia

including pulmonary, cardiac, kidney and liver. In

intravenous cannulas should be secured to take care

cardiac evaluation, an ECG (Electrocardiogram) and

of the blood and fluid loss replacement. Massive fluid

a baseline echocardiography should be done to rule

shifts can occur in patients with large ascites. Ascitic

out cardiomyopathy, pericardial involvement and

fluid drainage on opening the abdomen must be

ventricular

done

function

derangement.

Preoperative

and

and

slowly

to

preventing

perioperative

derangements.

Preinduction

surgery

avoid

[13].

Two

sudden

large-bore

hemodynamic

tapping of ascitic fluid may be beneficial in relieving

decompensation. Blood loss can be extensive due to

respiratory

continuous oozing and the nature of radical surgery.

distress.

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Co-existing

diseases

like

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Journal of Anaesthesia & Critical Care Invasive monitoring lines need to be secured for

warmers

guiding

management.

intravenous infusions. An indigenous low-cost blood

Preinduction arterial and central venous catheter

and fluid warmer made from gloves can be used if

insertion under ultrasound guidance can be done.

commercially available equipment is not available

Rapid sequence induction with cricoid pressure

[18]. Hourly urine output monitoring is mandatory to

(after

aspiration

ensure adequate renal perfusion as it accurately

prophylaxis) is usually recommended in patients with

reflects the status of intravascular volume. In these

massive ascites or with metastatic tumor causing

surgeries involving massive fluid shifts, a urine

intestinal or gastric obstruction. In patients in pre-

output of at least 0.5 - 1ml/Kg/hour should be

existing hepatic or renal impairment, Atracurium or

maintained. Other monitors of intravascular volume

cis-Atracurium can be used as the neuromuscular

status should be utilized to guide us regarding fluid

blocking agent, usually as a continuous infusion

infusions and the need for diuretic use. For

under neuromuscular monitoring [14]. Nitrous oxide

excessive protein loss, albumin infusions (salt-poor

is usually avoided to decrease the risk of air

20%

embolism

distension.

operatively. Some patients may require vasopressor

Endotracheal intubation with controlled mechanical

support to maintain an adequate mean arterial blood

ventilation is preferred, with caution to prevent

pressure in the perioperative period. Blood loss

hypotension on induction [15]. The Fraction of

replacement should be done according to standard

Inspired Oxygen (FiO2) has to be limited in patients

protocols

who have undergone chemotherapy with Bleomycin

allowable blood loss) [19]. Estimation of blood loss

and its analogues [16]. Inhalational agents with O 2 +

has to be meticulous as blood may be mixed with

Air

with

ascitic and serous fluid. In patients coming for

continuous Propofol infusion under intraoperative

interval debulking after neoadjuvant chemotherapy

BIS (Bi-Spectral Index) monitoring. Two important

or re-do surgery after primary debulking, the amount

considerations in patients with ascites and advanced

of blood loss may be greater in view of fibrosis. In

ovarian cancer are the prevention of hypothermia

cases with excessive blood loss due to extensive

and maintenance of adequate urine output. Ensuring

resections

normothermia may be difficult as there is continuous

complications of massive blood transfusion must be

oozing from the large, exposed peritoneal surfaces.

kept in mind. Intravenous calcium gluconate may be

Active warming measures should be adopted in the

infused to prevent hypercitratemia after 4 or 5 units

form of warm intravenous fluids and cleaning

of blood transfusion. Metabolic derangements are

solutions, raising the ambient temperature of the

common during extensive ovarian laparotomies.

operating room, patient warming blankets, using

Arterial blood gas analysis may be done to assess

warm fluids for abdominal wash and covering all

the level of base deficit, lactic acidosis, oxygenation

exposed areas of the body [17]. Electric fluid

and anion gap. Electrolyte imbalances necessitating

intravascular

adequate

mixture

volume

preoxygenation

and

can

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reduce

be

and

bowel

administered

along

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can

be

Review Article

used

albumin solution)

after

for

during

can be

calculation

optimal

of

large

infused

MABL

debulking,

volume

all

intra-

(maximal

possible

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Review Article

correction may occur in the perioperative period due

parameters, development of complications, choice

to fluid shifts, diuretic use and blood or blood product

and dose of anesthetic and analgesic drugs. Both

transfusion. Particular attention should be paid

invasive and non-invasive monitoring devices can be

towards potassium balance, as both hypo- and

utilized for improving patient outcome. Apart from

hyperkalemia are common [20]. There may be

routine standard ASA monitors (SpO2, ECG, NIBP,

vitiation of glycemic control in diabetic patients

Temperature and ETCO2), neuromuscular monitor,

during

BIS, airway and cuff pressure gauges, urine output

these

intravenous

extensive

insulin

surgeries.

infusion,

Titrated

piggy-backed

with

and

ventilatory

parameter

monitoring

in

dextrose infusion and hourly blood sugar monitoring

recommended for such extensive surgeries. Newer

can be extremely beneficial. Particular attention must

measures of tissue perfusion and intravascular

be paid to ensuring complete asepsis during all

volumes like the perfusion index, pleth variability

procedures

index,

as

these

patients

are

caval

index

and

co-oximetry

have

immunosuppressed [21]. Special precautions should

revolutionized the field of perioperative monitoring in

be taken while caring for invasive lines and epidural

high-risk patient population [22]. A recent addition to

catheters. Epidural analgesia must be offered to all

the existing armamentarium of monitors is the use of

patients,

pre-existing

intraoperative lung scanning with ultrasound. Not

coagulopathy. Not only does it reduces anesthetic

only does it provide information regarding lung zone

requirements and stress of surgery, but also reduces

status

doses of systemic opioids and delays cancer

consolidation), but also about extravascular lung

recurrence. Most of these patients can be extubated

water, pneumothorax and pleural conditions. In

in the operating room post surgery, provided they

patients with concurrent cardiac conditions, there is

are hemodynamically stable with good respiratory

also

efforts. If a pleural rent occurs in the course of

(Transesophageal Echocardiography) for measuring

optimal debulking, then a chest tube should be

various cardiac parameters in non-cardiac surgeries

inserted before abdomen closure and extubation. All

[23]. TEE probe can be inserted atraumatically in

of them need to be observed in an onco-surgical

high-risk cases into the oseophagus after anesthesia

intensive care unit with complete monitoring. DVT

induction and endotracheal intubation. They provide

prophylaxis, both mechanical and pharmacological

real-time views of various cardiac chambers and

as well as PONV (Postoperative Nausea Vomiting)

giving vital information about the ventricular filling

prophylaxis needs to be given to all these patients.

pressures, contractility, presence of thrombus and

provided

there

is

no

(atelectasis,

recent

pleural

evidence

of

effusion

using

and

TEE

intravascular volume status. With the advancement

Monitoring

in biotechnology and the advent of novel monitors

Monitoring for ovarian cancer laparotomy

like Vigileo TM and FloTrac TM, the use of invasive

must be extensive in order to guide us regarding

monitors like the PA (pulmonary artery) catheters

fluid therapy, replacement of blood loss, ventilatory

has drastically reduced [24]. Securing of arterial line

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for invasive blood pressure and arterial blood gas

fluid shifts, blood loss and dyselectrolytemias.

analysis is helpful in beat-to-beat monitoring, pulse

Thermal stress causes a hyperdynamic circulatory

contour analysis and detecting perioperative acid-

state

base disturbances. Serum lactate levels give a fair

management and hemodynamic monitoring [30].

estimate of the adequacy of tissue perfusion and in

Blood and blood product availability must be ensured

assessing metabolic acidosis [25]. In patients

in the blood bank prior to induction. Coagulopathy is

undergoing HIPEC after cytoreductive surgery, TEG

the result of dilution of platelets and coagulation

(Thromboelastography) can be used to monitor the

factors by large volume fluid infusions. The other

intraoperative coagulation status [26]. Nevertheless,

important anesthetic considerations include protein

one must remember that an astute and a vigilant

loss, increased intra-abdominal pressure, decreased

anesthesiologist is the best monitor.

oxygen delivery to the microcirculation, rise in

stands

for

warrants

meticulous

volume

metabolic rate and extremes of body temperature.

Anesthetic considerations for HIPEC HIPEC

which

Heat stress leads to increase in heart rate, cardiac

hyperthermic

output and end tidal carbon-dioxide, resulting in fall

intraperitoneal chemotherapy. It was first used in

in

1980

of

peripheral vasodilatation. It is prudent to keep the

pseudomyxoma peritonei [27]. In the recent times,

core temperature at 35 degrees Celsius before the

HIPEC when combined with cytoreductive surgery

start of hyperthermic chemotherapy so that the core

has been proved to be better than the use of

temperature is maintained below 38 degrees Celsius

intravenous chemotherapy. There have been several

during the procedure [31]. Anesthesiologists must

case reports and review articles citing the utility and

remember to switch off patient and fluid warmers

anesthetic considerations

[28]. The

before the start of HIPEC, to prevent dangerous

peritoneal cavity is filled with high-dose heated

hyperthermia. The ultimate goal is to maintain

chemotherapeutic solution resulting in a large

normothermia, as both hypo-and hyperthermia are

exposure of tumor cells to high-dose chemotherapy.

deleterious to the patient. The anesthesiologist must

This has been shown to increase the drug’s

ensure adequate intravenous fluid hydration as well

therapeutic effect due to selective hyperthermia-

as good hourly urine output (1-2ml/Kg/hour). Further,

induced cytotoxicity of malignant cells. Anesthetic

heated chemotherapeutic agents like Cisplatin can

implications are primarily due to disturbances in

cause nephrotoxicity. The introduction of HIPEC has

coagulation,

gas

improved both the 5-year survival rate and the

exchange and thermoregulation [29]. The pre-

median survival rate in ovarian cancer patients [32].

anesthetic assessment must focus on co-morbidities

Anesthesiologists must be geared up to face the

which may be exacerbated by the large fluid shifts

newer challenges posed by these advancements in

during the heated chemotherapeutic phase. It is a

oncologic treatments.

by

Spratt

et

al

for

the

treatment

of HIPEC

hemodynamics,

respiratory

SVR

(Systemic

Vascular

Resistance)

and

complex, long-duration surgery with resultant large

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vigilance is the key to improving post-surgical patient

Postoperative Care

survival. Meticulous

postoperative

care

is

the

cornerstone of successful anesthetic management of ovarian

cancer

patients.

Monitoring

of

vital

parameters, including arterial and central venous pressures should be continued. All patients should be kept adequately warm. Pain relief should be instituted through an epidural infusion (continuous or patient controlled analgesia) of local anesthetics combined with an opioid. Adequate analgesia ensures that the patient generates sufficient vital capacity, thus preventing postoperative atelectasis 33. Hourly urine output charting and VAS (Visual Analogue Score) assessment should be done. Insulin and dextrose infusions must be continued in the postoperative period in diabetic cancer patients for better would healing and prevention of ketosis. DVT prophylaxis should be instituted in the form of calf

pumps,

subcutaneous

compression LMWH

stockings

(Low

Molecular

and Weight

Heparin). Patients undergoing extensive resections or massive fluid shifts with co-existing organ system derangements may require a short period of postoperative

ventilation

to

take

care

of

the

interstitial edema and hemodynamic instability. Respiratory parameters, ABG (Arterial Blood Gas Analysis) analysis and postoperative lung ultrasound scanning can guide us regarding extubation in the onco-surgical intensive care unit [34]. Ovarian cancer patients with co-existing cardio-respiratory problems

have

postoperative ischemia,

a

high

risk

complications arrhythmias,

pneumothorax

and

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of like

developing myocardial

respiratory

pulmonary

edema.

Pain Management

failure, Eternal

Adequate perioperative pain management is the cornerstone of successful cytoreductive surgery program for ovarian cancer patients.

Epidural

analgesia is required, considering the length of incision and amount of retraction done during surgery. A combination of Ropivacaine (0.25%) and Sufentanil (10-15 micrograms) through continuous epidural infusion can be given, where available. Bupivacaine (0.25 – 0.125%) with Fentanyl (20-30 mcg/hour) can also be infused. Thoracic Epidural Analgesia (TEA) is beneficial in decreasing oxygen consumption and improving lung function, apart from reducing the overall stress response. Epidural analgesia is also known to reduce cancer recurrence in these patients. In addition, epidural analgesia is associated with decreased perioperative need of opioids

and

postoperative

ventilation.

Patient

Controlled Analgesia (PCA) is the current dictum, as not only does it gives a basal dose of the drug, but also gives a sense of control over the pain for the patient by giving additional bolus doses as desired [35].

Both

PCEA

(Patient

Controlled

Epidural

Analgesia) and PCIA (Patient Controlled Intravenous Analgesia) can be utilized as required. PCIA can be used

in

patients

with

coagulopathies

or

on

anticoagulants. For patients in whom epidural catheter is contraindicated, ultrasound guided TAP (Transversus Abdominus Plane) block can be given for postoperative analgesia. Care has to be taken in patients undergoing HIPEC, as they are prone to develop derangements in coagulation due to large

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fluid shifts, protein loss, hyperthermic chemotherapy

long-term venous access. Chemo-port insertion

and

usually

fall

in

antithrombin-III

levels.

Multimodal

is

done

under

local

anesthesia

and

analgesia is effective for pain management in these

Monitored Anesthesia Care (MAC) [39]. The main

patients and helps in earlier postoperative recovery.

entry sites include right internal jugular vein (most

In

addition

to

analgesia,

NSAIDs

common and the most favored), followed by right

is

function

subclavian, left internal jugular and the inferior vena

derangement), intravenous Paracetamol and low

cava. The success rate is improved with concurrent

dose opioids can be supplemented. In a recent

image guidance by ultrasound and fluoroscopy.

study, it was found that intraoperative neuraxial

Anesthesiologists need to be aware of the possible

anesthesia

neuraxial

complications of chemo-port insertion, in order to be

analgesia is associated with increased relapse free

ready to successfully manage the eventualities. The

survival after primary cytoreductive surgery for

major

ovarian

epidural

puncture, pneumothorax, air embolism, hematoma

anesthesia resulted in increased time to tumor

formation, arrythmias and cardiac arrest. The most

recurrence after ovarian cancer surgery, which may

common

be due to preservation of the immune system

blockade, infection, catheter malposition, venous

function. In another study done on advanced ovarian

thrombosis,

cancer patients in Chilean population, no benefit in

Coagulopathy

overall survival or time to recurrence was found

contraindications to chemo-port insertions, apart

among FIGO stage IIIC and IV of carcinoma ovary,

from patient refusal. Anesthesiologists need to be

after the use of epidural analgesia during and after

careful regarding the dose of sedatives and local

tumor de-bulking [37]. Patients with recurrent or

anesthetics administered during the procedure to

metastatic ovarian cancer may experience chronic

avoid over-sedation and local anesthetic toxicity.

pelvic

abdominal

Proper ASA fasting guidelines and monitoring

discomfort. Ultrasound or fluoroscopy-guided chronic

standards must be strictly followed during the entire

pain blocks can be given in the operation theatre by

procedure. A major advancement in this regard is

interventional pain physicians [38]. These include

the development of Intraperitoneal Chemoport (IPC)

pudendal nerve block, hypogastric plexus block,

insertion in stage 3c and 4 ovarian cancer patients

facet blocks, ganglion impar block and intrathecal

[40]. It is considered better than intravenous

pumps.

chemotherapy

(contraindicated

if

there

and

cancer

pain

epidural

or

not

[36].

low

renal

postoperative

Intraoperative

backaches

or

immediate

early

complications

complications

catheter and

as

include

dislodgement sepsis

it

include

can

are

be

used

arterial

catheter

or

leak.

the

main

for

both

intraoperative and post-operative chemotherapy. It

Chemotherapy and Radiotherapy

must be realized that HIPEC can only be used

As chemotherapy for ovarian cancer (both

intraoperatively as compared to IPC insertion,

neo-adjuvant and adjuvant) is given over several

through which upto 6 doses of chemotherapy can be

cycles, it is preferable to insert a chemo-port for

administered postoperatively. IPC insertion requires

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the administration of general anesthesia, which has

sedation to such patients for radiotherapy. Venous

its own concerns in advanced ovarian cancer

cannulation may be difficult in such patients. Patients

patients. There are several chemotherapeutic agents

may present in an advanced stage of cancer with

approved for ovarian, fallopian tube, or primary

affliction of multiple organ systems. Standard ASA

peritoneal cancer by the FDA (Food and Drug

guidelines for MAC (Monitored Anesthesia Care)

Administration, USA) [41]. Amongst them, Platinum

must be followed in all such cases. Anesthetic

analogues (Cisplatin, Carboplatin), Mitomycin C,

management in remote locations may become a

Bevacizumab,

challenge in such high-risk cancer patients.

Cyclophosphamide,

Gemcitabine,

Paclitaxel

and

Doxorubicin,

Topotecan

are

frequently prescribed in various combinations. All

Conclusions

these agents are prone to cause innumerable side

Anesthesia

for

ovarian

cancer

surgery

effects and affect various organ systems. Hence pre-

involves a thorough pre-operative assessment,

anesthetic evaluation of these patients has to be

vigilant intraoperative management and meticulous

thorough and extensive. The recent development of

postoperative care with extensive monitoring and

liposomal Doxorubicin Hydrochloride has reduced

adequate analgesia. The major anesthetic goals

the

include maintaining hemodynamic stability during

incidence

of

side-effects.

Anesthetic

considerations for patients on chemotherapy include

massive

the

especially

analgesia, prevention of hypothermia and correction

echocardiography; Kidney function evaluation and

of metabolic or electrolyte derangements. Recent

intraoperative

Intraoperative

advances in surgical techniques, revision of staging

restriction of FiO2 to as minimum as possible to

criteria, addition of newer chemotherapeutic agents,

avoid

novel monitoring devices, better anesthetic care and

following:

lung

toxicity);

Cardiac

renal

injury

evaluation,

protection;

(Bleomycin

view

epidural

pain management has improved overall patient survival. In particular, the advent of HIPEC following

system functions. Radiotherapy is not used as the

optimal cytoreductive surgery has opened new doors

first line for treatment of ovarian cancer, but more

in the management of patients with advanced or

often to treat cancer spread [42]. External beam

metastatic ovarian cancers. Nevertheless, these

radiotherapy is the mainstay of radiotherapy in

have raised several issues regarding patient safety,

ovarian carcinoma. The major side-effects include

which have to be addressed by the anesthesiologists

skin changes, fatigue, diarrhea, nausea and vaginal

and onco-intensivists. Team effort by surgeons,

irritation. Brachytherapy is rarely used for this type of

gynecologists, oncologists, anesthesiologists and

cancer. In the past, radioactive phosphorous was

other supportive staff can go a long way in ensuring

used for intra-abdominal instillation, but was stopped

a

due

physicians also have an important role in improving

intestinal

in

administering

immunosuppression; and Evaluation of other organ

intractable

asepsis

oxygen

shifts,

of

to

Complete

induced

fluid

side-effects.

complete

cancer

cure.

Interventional

pain

Anesthesiologists may be called upon to administer

Volume 2: Issue 1

ISSN: 2424-8673

10


Review Article

the quality of life and providing a pain-free survival of

neoadjuvant

advanced ovarian cancer patients.

interval debulking surgery in advanced ovarian

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