Daniela Viscardi

A 7-Year Retrospective Multisource Analysis on the Incidence of Anesthesia Awareness With Recall in Cancer Patients: A Chance of Collaboration Between Anesthesiologists and Psycho-Oncologists for Awareness Detection.

Abstract Although randomized controlled studies reported an incidence of anesthesia awareness with recall ∼1 to 2 per 1000 (0.1–0.2%), recent data from the NAP5 study showed an incidence of only 1:19,600. Although in a prospective study many tools for anesthesia awareness detection can be used, a retrospective analysis requires a careful collection of information. The aim of the study was to evaluate the incidence of anesthesia awareness with recall in a cohort of cancer patients through a multisource retrospective analysis, and the clinical description, including the psychological outcome, of the cases detected. We also tested whether our retrospective analysis would be improved by a routinely psycho-oncological assessment. As secondary endpoints we evaluated the use of depth of anesthesia monitoring over a large cohort of patients, and the correlation between the brain monitoring and the incidence of awareness. We have carried out a 7-year retrospective analysis in a large cohort of cancer patients on the incidence of awareness with recall during general anesthesia. Of 35,595 patients assessed for eligibility, 21,099 were studied. We analyzed all data from the operative rooms’ database, the anesthesia records, and from the database of the surgical divisions. In addition we examined reports from psychologists and spontaneous reports to the quality team of the hospital. Two certain cases of awareness were detected, with an incidence of 1:10,550 (0.0095%). They occurred during elective surgery, in female patients without other risk factors. One case came from the report of a psychologist. In both episodes, brain monitoring was not applied and no long-term psychological sequelae were reported. Despite the limitations, our investigation suggests that the incidence of anesthesia awareness is very low, also in a specific cohort of patients, such as the cancer patients, and even when the depth of anesthesia monitoring is rarely used. The limitations caused by both the retrospective analysis and the absence of specific tools for direct awareness detection, such as structured interviews, can be filled with an effective postoperative psychological assessment which is often of routine in a cancer center. This observation could suggest the usefulness of inserting specific questions within the psychological tools commonly used by psycho-oncologists.

Erratum to: Multidisciplinary approach and anesthetic management of a surgical cancer patient with methylene tetrahydrofolate reductase deficiency: A case report and review of the literature (Journal of Medical Case Reports (2015) 9:175)

The original version of this article [1] unfortunately contained a mistake. The presentation of the author names is incorrectly marked up and therefore it is presented incorrectly in the HTML version of this article. The corrected author list is given below: Cascella M, Arcamone M, Morelli E, Viscardi D, Russo V, De Franciscis S, Belli A, Accardo R, Caliendo D, De Luca E, Di Caprio B, Di Sauro F, Giannoni G, Iermano C, Maciariello M, Marracino M, Cuomo A. The original article was corrected accordingly.

Multidisciplinary approach and anesthetic management of a surgical cancer patient with methylene tetrahydrofolate reductase deficiency: a case report and review of the literature

IntroductionHyperhomocysteinemia is a known risk factor for myocardial infarction, stroke, peripheral vascular disease, and thrombosis. Elevated plasma homocysteine levels have been demonstrated in patients with recurrent episodes or a single episode of thrombosis. Here we describe the development of cardiovascular disease as a complication of a surgical intervention in a patient with colorectal cancer and hyperhomocysteinemia.Case presentationA 65-year-old Caucasian man complained of pain and constipation, attributed to previously diagnosed adenocarcinoma (stage IIB) of the hepatic flexure. An anamnestic investigation showed that he had undergone two surgical interventions. During both, he suffered thrombotic postoperative complications, a deep vein thrombosis of the upper extremity after the first operation and retinal vein occlusion after the second. He was diagnosed with hyperhomocysteinemia associated with a homozygous C677T mutation of the gene encoding the enzyme methylenetetrahydrofolate reductase. Our patient was initially treated with folic acid and high-dose B vitamins. On day 7 he underwent a right hemicolectomy. Anesthesia was performed with sevoflurane in 40% O2 and without the use of nitrous oxide. Postoperatively, our patient remained on folic acid and B vitamins and was without immediate or subsequent complications.ConclusionsNeoplastic disease and related surgery followed by the administration of chemotherapeutic drugs alter the hemostatic balance in cancer patients. Those suspected of also having a thrombophilic disease require a thorough laboratory diagnostic workup, including a molecular analysis aimed at identifying the genetic mutation responsible for the hyperhomocysteinemia, as indicated. The case described in this report highlights the importance of a multidisciplinary approach that includes expertise in peri-operative anesthesia, surgery, oncology, and hematology.

Features and Role of Minimally Invasive Palliative Procedures for Pain Management in Malignant Pelvic Diseases A Review

Pain is a common and debilitating symptom in pelvic cancer diseases. Failure in controlling this pain through pharmacological approaches calls for employing multimodal management and invasive techniques. Various strategies are commonly used for this purpose, including palliative radiotherapy, epidural medications and intrathecal administration of analgesic and local anesthetic drugs with pumps, and neural or plexus blockade. This review focuses on the features of minimally invasive palliative procedures (MIPPs), such as radiofrequency ablation, laser-induced thermotherapy, cryoablation, irreversible electroporation, electrochemotherapy, microwave ablation, and cementoplasty as well as their role in palliation of cancer pelvic pain. Despite the evidence of effectiveness and safety of these interventions, there are still many barriers to accessing MIPPs, including the availability of trained staff, the lack of precise criteria of indication, and the high costs.

Pelvic Pain in Different Cancer Diseases

The pain may have various characteristics according to the different pelvic neoplastic diseases (Table 3.1). The features and the latency of the symptoms depend on many factors, including the anatomy and innervation of the pelvis and the type of cancer and its progression.

Pain Syndromes Associated with Cancer Therapy

Cancer pain is mostly disease related; however, considering that the cancer incidence increases and the survival improves, thanks to the better oncological management, there is an increasing number of patients living with the long-term effects of treatments and potentially curative and/or palliative cancer treatments, including surgery, chemotherapy, and radiotherapy. These could be associated with chronic specific or unspecific iatrogenic pain syndromes, which have often a difficult and specific management especially when they are simultaneous with the cancer-induced pain syndromes.

Postoperative Massive Pulmonary Embolism Due to Superficial Vein Thrombosis of the Upper Limb

It is well known that deep vein thrombosis of the upper extremities is linked to high morbidity/mortality, resulting in 12-20% of all documented pulmonary embolism; however, there are few data about thromboembolism originating from a vein and/or a branch of a superficial vein of the upper extremities. Pulmonary embolism secondary to upper limb superficial vein thrombosis (not combined with upper extremities deep vein thrombosis) is a very rare clinical manifestation with few cases reported in the literature. We report a rare case of thrombophlebitis in departure from a superficial branch of the cephalic vein of the right arm, complicated by cardiac arrest secondary to a massive pulmonary embolism in a patient who underwent major surgery for ovarian cancer. We discuss on the numerous thrombotic risk factors, triggering a cascade of reactions and resulting in a potential fatal clinical manifestation.

General Features of Pelvic Cancer Pain

The pelvis contains manifold and complexly innervated structures that are potential sources of pain. As a consequence, in pelvic cancer diseases, several factors cause pain, such as the primary solid tumors of the pelvic organs and other pelvic tissues, the metastatic tumors, or the nodal conglomerates causing mass effect. Thus, the pelvic cancer pain is a clinical condition related to the involvement of viscera, pelvic muscular structures, or neural structures due to primitive tumors, local recurrences, or metastasis. Additionally, pain may also follow the treatments of the pelvic masses, for example, the chemotherapy, the radiotherapy, and the surgery.

Neurolytic Sympathetic Plexus Blocks

Pain from malignant involvement of visceral organs is conveyed along sympathetic pathways and may be amenable to interruption of these pathways [1] (see also Table 7.1).

Psychological, Behavioral, and Rehabilitation Approaches to Cancer Pain Management

Cancer pain is usually treated medically with pharmacological and non-pharmacological approaches; nevertheless, both patients and healthcare professionals often underestimate the impact of cancer pain on psychological distress and do not consider the potential benefits of psychological treatments to help manage cancer pain. According to Dame Cicely Saunders, cancer pain is a “total pain” because the patient’s pain experience has physical, emotional, social, and spiritual dimensions [1].