Diwakar D. Balachandran

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

Indwelling Pleural Catheters for Patients with Hematologic Malignancies. A 14-Year, Single-Center Experience

Rationale: Placement of an indwelling pleural catheter is an established modality for symptom relief and pleurodesis in the treatment of malignant pleural effusion. Concerns remain regarding possible infectious complications, risk of hemorrhage, and the rate of pleurodesis with the use of pleural catheters in the treatment of hematologic malignancies. Objectives: The goals of our study were: (1) to evaluate the safety and cumulative incidence of pleurodesis with indwelling pleural catheters for patients with hematologic malignancies, and (2) to evaluate overall survival of this cohort of patients with pleural effusions. Methods: We performed a retrospective review of 172 patients with a hematologic malignancy who underwent placement of an indwelling pleural catheter between September 1997 and August 2011 at the University of Texas MD Anderson Cancer Center in Houston, Texas. A competing risk model analysis was used for complications and pleurodesis. Analysis was based on each patients first intrapleural catheter. Results: There were 172 patients with lymphoma (58%), acute (16%) or chronic leukemia (16%), or multiple myeloma (10%). The effusions were characterized as malignant (85.5%), infectious (4.1%), volume overload (4.7%), or therapy‐related (4.7%). Chylothorax was found in 20.1%. Pleural biopsies were obtained from 13 patients. The cumulative incidence of all complications was 13.6%, and the cumulative incidence of all significant catheter‐related complications was 9.5%. The incidence of empyema was 2.9%, and major bleeding (requiring transfusion or intervention) was 1.7%. Thirty‐day procedure‐associated mortality was 0.6%. The cumulative incidence of pleurodesis at 180 days was 50%, with a median time to pleurodesis of 81 days for the entire cohort. Conclusions: Indwelling pleural catheters appear to be safe for patients with hematologic malignancies. Complications and the cumulative incidence of pleurodesis are comparable to those reported for patients with solid organ malignancies.

Managing Post-Pneumonectomy Tension Hydrothorax

A 67-year-old woman with a history of high-grade spindle cell sarcoma of the left lung was admitted for progressive dyspnea on exertion, orthopnea, and fatigue. She had been treated with neoadjuvant chemotherapy followed by a left pneumonectomy 17 months previously. The pneumonectomy included a partial pericardiectomy and dissection of parenchymal–diaphragmatic adhesions. Chemotherapy had left her with ifosfamide-induced renal injury that resulted in end-stage kidney disease managed with chronic peritoneal dialysis. On admission, she reported progressive dyspnea with exertion over the previous 2 weeks along with left-sided chest discomfort. She denied any syncopal or presyncopal episodes. On examination, the patient was afebrile and tachycardic at 122 beats/min. The woman was normotensive with arterial oxygen saturation of 100% while she breathed room air. Physical examination demonstrated a woman who appeared anxious with jugular venous distention and a pulsus paradoxus measured at 12–14 mm Hg with bilateral lower extremity edema. A chest radiograph revealed total opacification of the left hemithorax with tracheal deviation to the right (Figure 1A). A computed tomographic (CT) scan of the chest showed significantly increased left pleural effusion compared with a prior study (Figure 2). An echocardiogram demonstrated diastolic collapse of the right ventricular outflow tract along with a dilated inferior vena cava with decreased respiratory variation consistent with cardiac tamponade (Figure 3). The left ventricular cavity was small with normal contractility, and a large left pleural effusion was visualized. Laboratory data were remarkable for elevated B-type natriuretic peptide (719 pg/ml), creatinine (7.94 mg/dl), and troponin-I (1.15 ng/ml). An urgent left-sided thoracentesis was performed with removal of 1.3 L of serosanguinous pleural fluid, resulting in rapid improvement of symptoms as well as normalization of heart rate and respiratory rate. The pleural fluid was exudative, with the following: lactate dehydrogenase, 598 IU/L; total protein, 4.1 g/dl; cholesterol, 97 mg/dl; and glucose, 85 mg/dl. Cytology and routine cultures were negative for malignancy and microorganisms. Subsequent rapid fluid reaccumulation and recurrence of symptoms after 2 days led to placement of an indwelling pleural catheter for definitive management.

Cancer-related fatigue presenting with excessive daytime sleepiness

Cancer-related fatigue is a common symptom in cancer patients which commonly occurs in relation to sleep disturbance. We report a case of a 35-year-old breast cancer survivor, in whom polysomnography and multiple sleep latency testing were utilized to objectively quantify the contribution of excessive daytime sleepiness to the patient’s cancer-related fatigue.