avoiding opioid use in cancer surgery

[coffeebythelake]

Some of my colleagues have been avoiding opioids altogether (and using ketamine) for cancer surgery, based on some animal and in-vitro studies showing that opioids may lead to immunosuppression of protective mechanisms and may increase risk of cancer recurrence. From what I've read it is mostly with morphine and there has not been any RCTs performed for this.

I haven't jumped on the bandwagon on this. Most of the attendings here like to use remi for head and neck, other surgeries where there is neuro monitoring. What is your practice? Yea? Nay?

---

Members don't see this ad.

 

[dannyboy1]

Some of my colleagues have been avoiding opioids altogether (and using ketamine) for cancer surgery, based on some animal and in-vitro studies showing that opioids may lead to immunosuppression of protective mechanisms and may increase risk of cancer recurrence. From what I've read it is mostly with morphine and there has not been any RCTs performed for this.

I haven't jumped on the bandwagon on this. Most of the attendings here like to use remi for head and neck, other surgeries where there is neuro monitoring. What is your practice? Yea? Nay?

Just stick the tube in and use your usual cocktail. Let the surgeon cut the cancer out and the oncologist handle the treatments. A lot of these studies seem to spring from the hope that we are “real doctors”. Look! We are treating cancer! I call BS....

 

[linkin06]

One could also argue that having poorly controlled pain and sympathetic leads to cortisol production and Immune suppression. I did my ca3 talk on this. The overall evidence seems iffy. lots or flawed data I’d say. Hard to do RCT. I personally felt most convinced by epidural use for colon resection. Hard to convince the surgeons though unless you develop a full fledged pain service. they don’t want to have to deal with an epidural.

 

[nimbus]

Why pick on opioids? Everything we use may modify the risk of cancer recurrence. IMO that practice is getting ahead of the science.

 

[AdmiralChz]

The evidence on this is... questionable at best, and as you said primarily from in-vitro or animal studies. Wait for more conclusive studies.

Are you avoiding inhalation all agents too and doing TIVAs for these cases? The evidence base is there but meta-analyses haven’t borne out as much promising results as early studies

 

[deleted162650]

Why pick on opioids? Everything we use may modify the risk of cancer recurrence.

That’s why I do all my big cancer whacks awake.

 

[PieOHmy]

Some of my colleagues have been avoiding opioids altogether (and using ketamine) for cancer surgery, based on some animal and in-vitro studies showing that opioids may lead to immunosuppression of protective mechanisms and may increase risk of cancer recurrence. From what I've read it is mostly with morphine and there has not been any RCTs performed for this.

I haven't jumped on the bandwagon on this. Most of the attendings here like to use remi for head and neck, other surgeries where there is neuro monitoring. What is your practice? Yea? Nay?

I didnt hear opioids but i heard volatile agents may be bad.
So no volatile agents, no opioids, no nitrous.
Just ketamine sux and tube.,.
ridiculous

 

[coffeebythelake]

The evidence on this is... questionable at best, and as you said primarily from in-vitro or animal studies. Wait for more conclusive studies.

Are you avoiding inhalation all agents too and doing TIVAs for these cases? The evidence base is there but meta-analyses haven’t borne out as much promising results as early studies

I ask before one of the well published professors of anesthesiology in my department, who is also an editor of one of the major anesthesiology journals, has been trying to convince others to use ketamine instead of opioids claiming "compelling evidence".

Personally I dont think the data is applicable to real patients or strong enough to support a change in my practice. Unless there is hard evidence I will continue to give opioids and use sevo for cancer patients.

 

[MoMoGesiologist]

Ugh... don’t all these cancer pts get narcotics written by their oncologists and surgeons anyway? Why would us using fentanyl increase cancer risk when their primary doctors are writing narcotics anyways for chronic cancer pain and post op pain?

 

[nimbus]

I didnt hear opioids but i heard volatile agents may be bad.
So no volatile agents, no opioids, no nitrous.
Just ketamine sux and tube.,.
ridiculous

Ketamine might be bad too

 

[DoctwoB]

Urologist here. Our cancer whacks are done using TAPs, TIVA and ketamine, no/minimal narcs. Can’t speak to changes in cancer control, but can definitely say that patients are more mobile earlier with less nausea and issues with pain control compared to prior regimens with narcs and inhalational. If you told me five years ago that a cystectomy would need 0 opiates in the post operative period I would have said you were lying. Now that’s our routine.

 

[PieOHmy]

Urologist here. Our cancer whacks are done using TAPs, TIVA and ketamine, no/minimal narcs. Can’t speak to changes in cancer control, but can definitely say that patients are more mobile earlier with less nausea and issues with pain control compared to prior regimens with narcs and inhalational. If you told me five years ago that a cystectomy would need 0 opiates in the post operative period I would have said you were lying. Now that’s our routine.

That is impressive.

 

[MoMoGesiologist]

Urologist here. Our cancer whacks are done using TAPs, TIVA and ketamine, no/minimal narcs. Can’t speak to changes in cancer control, but can definitely say that patients are more mobile earlier with less nausea and issues with pain control compared to prior regimens with narcs and inhalational. If you told me five years ago that a cystectomy would need 0 opiates in the post operative period I would have said you were lying. Now that’s our routine.

With your TIVA, there is no remifentanyl or sufentanil infusion? You have tracked numbers and see significant decrease in post op narcotic requirements? That sounds great for your patients, congrats.

 

[deleted875186]

Agreed that there is no compelling study for either opioids or volatile with cancer recurrence last I looked.

My personal opinion, not backed anything, is that there is some immunomodulatory effect from what we do but it will never be clinically significant. I do what I would do for any other type of surgery, multimodal, limit opioids as much as possible, and TIVA if there is an indication.

 

[DM27]

When I was in late residency the theory that volatile anesthetics, and to a lesser extent opioids, may have a role in cancer recurrence was strongly in vogue and I remember a few studies being done to investigate this specifically. The few that I have been able to find on this have not had results that are especially convincing that this is actually the case.

 

[deleted697535]

I do tiva for as many female cancer surgery pts as I can. It's a good learning tool as I find most of my colleagues or residents haven't a clue about real tiva. They couldn't even name a TCI algorithm never to mind actually describe one of them in detailed pharmacokinetics as a consultant in anesthesia should be able to. It's bloody propofol ffs. Lay people know more about it than some of us! Can't read raw eeg, set up is terrible with IVs tucked, no no return valves etc etc

Learning tool aside, I Think the tiva probably lowers ponv which destroys these women psychologically plus their families. And it if has even a slightest chance of reducing cancer recurrence then why not do it?

Possibly better for environment and cheaper...
Plus I can time my wakeup even with longer 4 to 6 hour surgery to 5 mins or whatever time I want.

 

[deleted162650]

Plus I can time my wakeup even with longer 4 to 6 hour surgery to 5 mins or whatever time I want.

That just means you need to get better with volatile.

 

[coffeebythelake]

That just means you need to get better with volatile.

Yeah I cant believe that was listed as a reason

 

[Mman]

While I find the theoretical idea that volatile or opioids can contribute to cancer recurrence interesting, the actual science behind it is severely lacking especially when you consider publication bias in favor of studies that show even the slightest effect. In truth it probably makes no difference.

 

[deleted697535]

Yeah I cant believe that was listed as a reason

Why?

You think smooth, predictable wakeup isn't important?

 

[deleted162650]

Why?

You think smooth, predictable wakeup isn't important?

Oh it’s important. But it’s easily achievable with volatile. It’s the Indian not the arrow dude.

 

[deleted697535]

You guys are funny. You pick out one tiny aspect of a post and decide to complain about it despite the fact that what you're saying against it is debatable at best.

Man we all know how to dial down sevo to 0.5 mac or whatever. Thats easy. Can you tell me an effect site concentration for sevo after a 6 hour surgery in a bmi 60 patient who is prone? Will you dial down your sevo then to 0.4? Please enlighten me with your arrow and indian?

 

[Mman]

You guys are funny. You pick out one tiny aspect of a post and decide to complain about it despite the fact that what you're saying against it is debatable at best.

Man we all know how to dial down sevo to 0.5 mac or whatever. Thats easy. Can you tell me an effect site concentration for sevo after a 6 hour surgery in a bmi 60 patient who is prone? Will you dial down your sevo then to 0.4? Please enlighten me with your arrow and indian?

waking people up on a dime no matter the technique is what we train for and what we get paid to do.

 

[PieOHmy]

This is an important point because the newer generation think propofol wake up is smoother.. It may be smoother because the patients are ASLEEEP when extubated with frequent hypoventilation in pacu. Ive seen folks use volatile agents for a four hour case and at the end turn the gas off and titrate in propofol. Ive seen a few people do this. Is this being taught.. I found that to be soo amateurish and counter-intuitive. When I was in training if i ever did that I would have my ass handed to me

 

[deleted697535]

waking people up on a dime no matter the technique is what we train for and what we get paid to do.

Great.

Ok here you go then. Please tell me how you wake up on a dime?

BMI 60. 140kg, 35 yo Female prone. 6 hour case. Lets say no other medical issues.

 

[deleted697535]

This is an important point because the newer generation think propofol wake up is smoother.. It may be smoother because the patients are ASLEEEP when extubated with frequent hypoventilation in pacu. Ive seen folks use volatile agents for a four hour case and at the end turn the gas off and titrate in propofol. Ive seen a few people do this. Is this being taught.. I found that to be soo amateurish and counter-intuitive. When I was in training if i ever did that I would have my ass handed to me

Thats an entirely different but also concerning issue.
TIVA is very different to this type of thing. There are no models or science to what you speak of so i dont know how anyone could figure out where they are there other than winging it, which is fine sometimes

 

[deleted162650]

Sounds like somebody shoulda signed up for that emergence fellowship.

 

[deleted697535]

Sounds like somebody shoulda signed up for that emergence fellowship.

lol, if your answer is drop sevo to 0.x Mac then im good man. Thats high level stuff. How do i sign up for this fellowship?

TIVA for you guys = If they move a bit give em some more

Thats a quote from this board a few months back lol. Dont mind compartment models and effect site concentrations. Thats all BS... I agree

 

[deleted162650]

Thats high level stuff.

Apparently it is for some people.

 

[PieOHmy]

Great.

Ok here you go then. Please tell me how you wake up on a dime?

BMI 60. 140kg, 35 yo Female prone. 6 hour case. Lets say no other medical issues.

Thats cheating. You have to figure it out with experience baby... Not on a board..
I have the answer by the way.

 

[Mman]

Great.

Ok here you go then. Please tell me how you wake up on a dime?

BMI 60. 140kg, 35 yo Female prone. 6 hour case. Lets say no other medical issues.

practice. Not that hard. A 6+ hour TIVA almost always slower to wake up than using volatile no matter how awesome your TCI algorithm.

 

[MoMoGesiologist]

They couldn't even name a TCI algorithm never to mind actually describe one of them in detailed pharmacokinetics as a consultant in anesthesia should be able to. It's bloody propofol ffs. Lay people know more about it than some of us!

What is the relevance of this? Not trying to be rude, but why does the TCI algorithm and detailed PK matter?

 

[Mman]

What is the relevance of this? Not trying to be rude, but why does the TCI algorithm and detailed PK matter?

TCI is not FDA approved in the US so is basically irrelevant to anesthesia in this country.

 

[deleted875186]

Ive seen folks use volatile agents for a four hour case and at the end turn the gas off and titrate in propofol. Ive seen a few people do this. Is this being taught.. I found that to be soo amateurish and counter-intuitive. When I was in training if i ever did that I would have my ass handed to me

I’ll be honest, I don’t see what is wrong with this. I think you can usually time your wake ups, but I see no problem with getting all your volatile off, and giving a little propofol if needed while closing or putting dressings in if needed. I’m just going to throw away my propofol left from induction anyway.

I often find this technique helpful in younger patients, where they may be light and move a bit while your getting the volatile off, a little propofol stops the surgeon or resident from complaining. If I keep them deep enough to be perfectly still during this they’ll take much longer to wake up.

 

[MoMoGesiologist]

This is an important point because the newer generation think propofol wake up is smoother.. It may be smoother because the patients are ASLEEEP when extubated with frequent hypoventilation in pacu. Ive seen folks use volatile agents for a four hour case and at the end turn the gas off and titrate in propofol. Ive seen a few people do this. Is this being taught.. I found that to be soo amateurish and counter-intuitive. When I was in training if i ever did that I would have my ass handed to me

You would have you ass handed to you for using propofol at the end of the case to smooth out extubation? Am I misunderstanding?

 

[psychbender]

You would have you ass handed to you for using propofol at the end of the case to smooth out extubation? Am I misunderstanding?

As one of my old attendings, who was very much against the practice, would say, "What the hell are you doing, giving them something to go to sleep when you're supposed to be waking them up?!?!"

Sent from my SM-G930V using SDN mobile

 

[PieOHmy]

You would have you ass handed to you for using propofol at the end of the case to smooth out extubation? Am I misunderstanding?

It doesnt smooth out extubation, it just puts the patients back to sleep or even worse in stage 2.
May look pretty to you, but not the safest practice and eventually i can see it being a real problem if its taught routinely to residents. Extubation criteria doesnt state give a smidge of propofol to smooth out extubation because I dont know what IM doing..

 

[coffeebythelake]

It doesnt smooth out extubation, it just puts the patients back to sleep or even worse in stage 2.
May look pretty to you, but not the safest practice and eventually i can see it being a real problem if its taught routinely to residents. Extubation criteria doesnt state give a smidge of propofol to smooth out extubation because I dont know what IM doing..

I dont know about you, but I have patients follow commands (open mouth, squeeze hands) before I pull the tube.

 

[PieOHmy]

I dont know about you, but I have patients follow commands (open mouth, squeeze hands) before I pull the tube.

 

[deleted697535]

TCI is not FDA approved in the US so is basically irrelevant to anesthesia in this country.

With all due respect this is quite a lazy response. The TCI pump may not be fda approved but the pharmacology behind it should be essential knowledge for any anesthesiologist

 

[fakin' the funk]

I dont know about you, but I have patients follow commands (open mouth, squeeze hands) before I pull the tube.

Why

 

[fakin' the funk]

So much braggadocio on this board about "slick" wakeups "on a dime"

Get a life y'all

 

[Mman]

With all due respect this is quite a lazy response. The TCI pump may not be fda approved but the pharmacology behind it should be essential knowledge for any anesthesiologist

we all understand pharmacology and pharmacokinetics for propofol and for volatile anesthetics. If someone struggles to use one of them, they should probably read and practice a bit more. The fun of our job is that there are a lot of ways to skin the cat and you should be an expert at many (all) of them because not every technique is appropriate for every patient/surgery.

 

[Mman]

So much braggadocio on this board about "slick" wakeups "on a dime"

Get a life y'all

nah, just pointing out we are all supposed to be skilled in many different techniques. Anybody arguing their one way is the best way to do it is almost always wrong.

 

[Arch Guillotti]

I do tiva for as many female cancer surgery pts as I can. It's a good learning tool as I find most of my colleagues or residents haven't a clue about real tiva. They couldn't even name a TCI algorithm never to mind actually describe one of them in detailed pharmacokinetics as a consultant in anesthesia should be able to. It's bloody propofol ffs. Lay people know more about it than some of us!

Sounds like your shop is pretty weak then

 

[2Fast2Des]

Problem with TIVA is keeping up with replacing the profofol syringes, I prefer a hands free low flow volatile technique (no refilling nada )

 

[nimbus]

I do tiva for as many female cancer surgery pts as I can. It's a good learning tool as I find most of my colleagues or residents haven't a clue about real tiva. They couldn't even name a TCI algorithm never to mind actually describe one of them in detailed pharmacokinetics as a consultant in anesthesia should be able to. It's bloody propofol ffs. Lay people know more about it than some of us! Can't read raw eeg, set up is terrible with IVs tucked, no no return valves etc etc

Learning tool aside, I Think the tiva probably lowers ponv which destroys these women psychologically plus their families. And it if has even a slightest chance of reducing cancer recurrence then why not do it?

Possibly better for environment and cheaper...
Plus I can time my wakeup even with longer 4 to 6 hour surgery to 5 mins or whatever time I want.

I can’t name a TCI algorithm. Educate this old dinosaur. And please describe one of your typical TIVAs. I am here to learn.

For reference, my TIVA is typically squirting ketamine 100mg into a 1000mg vial of propofol. Rarely I add remi 2mg into the mix. Start it at propofol 100mcg/kg/min and titrate to vitals and BIS. If I don’t put remi in the cocktail, I give fentanyl. Admittedly my volatile wakeups are usually faster than my TIVA wakeups.

Also I have zero experience with raw EEG. Never once saw it during my entire medical training or career. Am I supposed to know this?

 

[narcotics999]

Problem with TIVA is keeping up with replacing the profofol syringes, I prefer a hands free low flow volatile technique (no refilling nada )

Come on, you don't use IV pumps to do propofol drip? 100ml bottle runs for a while.

 

[2Fast2Des]

Come on, you don't use IV pumps to do propofol drip? 100ml bottle runs for a while.

I'd have to scout and harass pharmacy to send me them or run around the main pyxises around to see if they have them, we just have the 20 and 50 in our OR ones. It ain't that easy and certainly not worth the trouble unless the case deems it truly necessary, and I'd have to hunt someone down to find me an IV pump... Syringe it is for now...

 

[nimbus]

I'd have to scout and harass pharmacy to send me them or run around the main pyxises around to see if they have them, we just have the 20 and 50 in our OR ones. It ain't that easy and certainly not worth the trouble unless the case deems it truly necessary, and I'd have to hunt someone down to find me an IV pump... Syringe it is for now...

Every place is different. We have 3 bottles in our carts.