Anesthesia for Torsion testis patient in tumor lysis-final.pptx

tumor lysis is a common phenomenon in cancer patients on chemotherapy
such patient coming for surgical management is a challenge
such patients can deteriorate fast.
special care is needed to treat such patients.
case discussion is done for a patient of torsion testis.

1. Anesthesia for Torsion testis patient in tumor lysis syndrome- A CASE PRESENTATION DR NAYANA KULKARNI HCG MANAVATA CANCER CENTER NASIK.

2. CASE IN NUTSHELL 21 YR MALE PATIENT, HEIGHT 150 CM WEIGHT 34 KG, BMI- 14.5 C/O BREATHLESSNESS AND SEVERE DEABILITY AND LEFT SCROTAL SWELLING WITH severe PAIN. WAS INVESTIGATED FOR 1 MONTH {OUTSIDE} AND no treatment or biopsy done for diagnosis A CT SCAN SHOWED MULTIPLE METASTATIC LESIONS IN LUNGS AND LIVER, ABDOMEN ENCASING AORTA, IVC RENAL VEINS AND MEDIASTINUM. ALSO EXTENDING IN LEFT NECK CAUSING LEFT BRACHEO-CEPHALIC VEIN COMPRESSION AND PARTIAL LEFT APICAL LUNG COLLAPSE. DIAGNOSED TO HAVE TORSION OF LEFT TESTIS. WAS IN TUMOR LYSIS- HIGH LDH,BETA HCG AND AFP HIGH URIC ACID, POTASSIUM AND HYPOCALCEMIA WITH ARRHYTHMIA [ sinus tachycardia]

3. INVESTIGATIONS S. NO INVESTIGATION VALUE [28/11/23] VALUE [30/11/23] 1 Hb 8.9 8.3 2 WBC 14100 12220 3 PLATELET 51000 4 URIC ACID 10.0 5 CALCIUM 7.4 6 PHOSPHORUS 5.5 3.5 7 BILIRUBIN T[IND/DIRECT] 3.5 [2.3/1.2] 8 CREATININE 1.5 1.0 9 SODIUM 129.8 133 10 POTASSIUM 5.8 4.04 11 CHLORIDES 99 103 12 PT INR 1.3 1.1 13 SGPT 224 14 SGOT 806.2 15 ALK PHOSPHATASE 409.7 16 BUL 17.9 108 SR.NO INV VALUE [29/11/23] 17 TOTAL PROTEINS 5.8 18 ALBUMIN 2.8 19 GLOBULIN 3.0 20 LDH [U/L] 13676[N-MAX 450] 21 BETA HCG [ mIU/ml] 17700 [n- 0-3] 22 ALFA FETO PROTEIN [IU/ML] 1790 [n- 0-10] S no investigation Value [25/11/23] 1 Na 131 2 K 4.2 3 SGPT 96 4 SGOT 100 5 Hb 10.5 6 PLATELET 1.5 LACS 7 WBC 4200

4. ANESTHETIC CONSIDERATIONS Severe Cachexia- BMI less than 19.5. Cough Fever [99.5F] Hypoalbuminemia Jaundice. Hyperphosphatemia Hypocalcemia Glucose insulin drip for treating hyperkalemia [ 25% increase from baseline] Tumor lysis- spontaneous without treatment initiation.

5. Bed ridden- DVT risk , but- as platelets low, cannot start pharmacological dvt prophylaxis. Torsion of testis and severe pain – emergency case. Regional blocks- difficult as swelling and pain in inguinal region. Thrombophlebitis, left arm swelling , difficult venous access. Lung mets - GA is difficult as patient may have delayed recovery, drug interactions and there are reports of tumor lysis under GA too. Disoriented and apathetic, dehydrated, needs stabilization before intervention in limited period. Needs anesthesia plan which will allow good analgesia , good surgical field and rapid recovery postop without residual effects. Mild sedation and oxygen support.

6. Anesthesia plan As thrombocytopenia [count 48,000], SDP given and Repeat Pl count was 60,000. Then, patient taken for surgery. Hydrated and vitals monitored- preoperative optimization done. Unilateral spinal anesthesia decided. Left lateral position- [left testis torsion] pt couldn’t lie supine due to dyspnoea so 20 degree head up and lateral decubitus position O2 by mask. Preload 200 ml of fluid.(OVER 10 MIN) 1.0ml of 0.5% bupivacaine [heavy] with 27 Whitacre spinal needle . Drug injected over 3 min. Lateral position kept for 12 min, action at T9 level- checked. Surgery started, went over 70 min. Intraoperative mild sedation 1mg midazolam and antiemetic given

7. TREATING TUMOR LYSIS SYNDROME PREOP GUIDELINES Volume Expansion- Volume expansion is accomplished by crystalloids solutions, which increase the urine output and thus the phosphate, potassium, and uric acid excretion. Apart from this effect, salt delivery to the distal tubules increases potassium secretion and lowers kalemia. Decreasing the urinary calcium x phosphate product also prevents the precipitation of the crystals. Diuretics - Diuretics are not routinely recommended because they induce volume depletion, thus compromising the renal hemodynamics even more. Alkalosis - alkalinization decreases calcium phosphate solubility and favors crystals precipitation in renal tubules and soft tissues.

8. Alkalosis increases the amount of calcium that is bound to albumin and favors arrhythmia and tetany. Therefore, urine alkalinization is not recommended as it may even be dangerous. Treating Hyperphosphatemia - The main therapeutic measure is the increase in phosphaturia by volume expansion with isotonic solutions.

9. Calcium Supplementation Calcium is not routinely recommended, because it increases the precipitation of calcium in the soft tissues and it aggravates AKI. Calcium administration is recommended only in certain conditions: severe and symptomatic hypocalcemia (tetany, Chvostek sign,muscular fasciculation, bronchospasm, laryngospasm, seizures), changes of the electrocardiogram, and arrhythmia. In these cases, treatment is administered in order to alleviate the symptoms and not to normalize the calcemia.

10. Treating Hyperkalemia Hyperkalemia must be promptly treated because it can induce life threatening arrhythmias. When potassium value increases with more than 25% compared to baseline value or when kalemia reaches 6 mmol/L, cardiac monitoring is recommended, altogether with the standard treatment: beta-adrenergic agonists (albuterol), glucose-insulin solution, short calcium gluconate infusion for myocardial protection, loop diuretics, and potassium binding resins in order to increase digestive loss.

11. Tumor lysis syndrome (TLS) is the result of a series of events leading to the rapid death of a high number of malignant cells. Lysis of these cells leads to the release of intracellular ions and metabolic byproducts into the bloodstream, resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. All these disturbances may cause serious complications such as AKI, cardiac arrhythmias, seizures, and even death

12. TLS is an oncological emergency with high morbidity and mortality, especially if the diagnosis is delayed and treatment measures are not instituted promptly It may occur either spontaneously, or after antineoplastic therapy such as conventional chemotherapy, corticosteroids, molecular-targeted therapy, immunotherapy, and even after radiotherapy and Chemoembolization

13. 20. Cairo, M.S.; Bishop, M. Tumour Lysis Syndrome: New Therapeutic Strategies and Classification. Br. J. Haematol. 2004, 127, 3–11. [CrossRef]

14. Galoian, K.; Qureshi, A.; Wideroff, G.; Temple, H.T. Restoration of Desmosomal Junction Protein Expression and Inhibition of H3K9-Specific Histone Demethylase Activity by Cytostatic Proline-Rich Polypeptide-1 Leads to Suppression of Tumorigenic Potential in Human Chondrosarcoma Cells. Mol. Clin. Oncol. 2015, 3, 171–178. [CrossRef]

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