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Dr.H-Kayalha Anesthesiologist

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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.

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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.

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Have a nice day