The most common cancers in the pediatric population are acute leukemia, central nervous system (CNS) tumors, nephroblastoma, neuroblastoma, lymphoma, and sarcoma (see Chapter 45 ). The most common surgeries performed in pediatric patients with cancer are for central access for treatment (port or central line placement) and tumor resections. Caring for these children in the postoperative period requires knowledge of their cancer and previous therapies. Commonly, patients are often immunocompromised and may have single or multiple organ dysfunction or damage resulting from the disease or treatment-related effects. This may include cardiac dysfunction, radiation-induced tissue damage, acute or acute-on-chronic kidney injury, electrolyte imbalances, adrenal insufficiency, or malnutrition.
A systematic preoperative evaluation of the patient is vital for successful postoperative management. Discussion between the intensive care unit and anesthesia clinicians before surgery may help mitigate problems in the postoperative period. Postoperative planning includes the timing of extubation, the optimal location for immediate recovery from anesthesia, and the anticipation of pain control issues. These decisions should be communicated ahead of time with staff in the postanesthesia care unit (PACU), intensive care unit, and pediatric ward. In addition, a complete and thorough handoff should be provided between teams. An example of a handoff form is shown in Table 48.1 .
|Patient Identification (Name band check)|
|Duration/length of procedure||Hours, minutes|
|Surgical procedure and reason for surgery|
|Type of anesthesia (GA, TIVA, regional)|
|Surgical or anesthetic complications|
|Past medical history|
|Preoperative vital signs||T, HR, BP, RR, O 2 sat|
|Position of the patient (if other than supine)|
|Intubation conditions (grade of view, airway, quality of bag-mask ventilation)|
|Circulation/need for vasoactive medications||Stable/unstable|
|Fluid management (fluids in, estimated blood loss, urine output)||IVF/UOP|
|Analgesia plan during case, postoperative orders|
|Medications due for administration during PACU (antibiotics, etc.)|
|Other intraoperative medications (steroids, antihypertensives)|
The timing of extubation should be planned before the surgery begins. Extubation may occur immediately after surgery or be delayed for days in the intensive care unit due to airway risk (e.g., postoperative swelling), pulmonary edema, or hemodynamic instability. Patients who have undergone neurosurgery, oral-maxillary-facial surgery, or cardiac or thoracic surgery may benefit from postoperative mechanical ventilation for monitoring and management of tissue edema compromising the airway, or for hemodynamic and ventilatory optimization. Other considerations unique to pediatric patients with cancer include painful mucositis, restricted mouth opening (trismus), or a history of radiation to the neck requiring a well-planned process, given the potential for critical airway complications. Mucositis causes moderate to severe pain, friable oral tissue, edema, and bleeding. Restricted mouth opening may be seen in several pediatric conditions, including mandibular/temporomandibular joint radiation, Pierre Robin syndrome, Carpenter syndrome, Goldenhar syndrome, Crouzon disease, Freeman-Sheldon syndrome, Treacher-Collins syndrome, Klippel-Feil syndrome, ankylosing spondylitis, and rheumatoid arthritis (see Chapter 46 ). Macroglossia is associated with specific syndromes, including trisomy 21, Hurler syndrome, and Beckwith-Wiedemann syndrome, and can challenge reintubation or maintaining an oral airway. Radiation to the neck can cause tracheal stenosis, affecting the airway, and may require fiberoptic intubation and a smaller than average endotracheal tube size, especially if the need for reintubation arises. Neurosurgical procedures, especially those involving the posterior or infratentorial fossa, may affect cranial nerve function and lead to a neurologic pathology affecting breathing and swallowing.
Residual anesthesia effects may lead to upper airway obstruction due to the loss of pharyngeal airway tone. The tongue falls back against the posterior pharynx and obstructs the gas flow. Vocal cord swelling or subglottic edema that may occur with intubation can also cause upper airway obstruction and stridor. Cool mist, sedation, pain medications, racemic epinephrine nebulizer treatments, and intravenous dexamethasone are treatment options for airway edema causing stridor. In patients who have undergone thyroid, parathyroid, or aortic surgery, damage to the recurrent laryngeal nerve is possible. This may cause vocal cord paresis or paralysis, resulting in stridor or voice hoarseness. Patients undergoing neurosurgery of the posterior or infratentorial fossa may also have paresis or paralysis of the vocal cords, leading to vocal cord dysfunction and difficulty in breathing. In addition, cranial nerve deficits may also impair swallowing and weaken cough, leading to pooling and aspiration of secretions.
Residual anesthesia is the most common cause of respiratory failure after surgery. Volatile agents used for anesthesia, benzodiazepines used to decrease anxiety, or opioids used to manage surgical pain may cause prolonged sedation and respiratory depression. Lung protective ventilation strategies should be used in patients needing continued mechanical ventilation postoperatively. Inspiratory volumes up to 8–10 mL/kg, positive end-expiratory pressure (PEEP) of 5–8 cmH 2 O, and an age-appropriate respiratory rate should be used in patients with compliant lungs. In diseased lungs, acute lung injury, or respiratory distress syndrome, the mechanical ventilator volumes should be set to 4–8 mL/kg while maintaining plateau pressures of less than 30 cmH 2 O and allowing for permissive hypercapnia.
Pediatric oncology patients may experience lung injury before surgery due to direct pulmonary toxicity from chemotherapy or radiation. Bleomycin, busulfan, cyclophosphamide, and nitrosoureas are chemotherapeutic agents known to cause rales, fever, and dyspnea at therapeutic levels. Methotrexate, cytarabine, ifosfamide, cyclophosphamide, interleukin (IL)-2, all-trans retinoic acid, and bleomycin may cause endothelial injury and vascular leakage, which can lead to noncardiac pulmonary edema. Dose-dependent radiation damage can present with cough, dyspnea, and pink sputum up to 3 months after treatment. One to two years after treatment, radiation damage can cause fibrosis, increased oxygen requirement, and decreased pulmonary function. Reviewing previous cancer therapies, current symptoms, chest imaging, and previous pulmonary function testing can provide helpful knowledge regarding lung damage.
Discontinuing mechanical ventilation immediately postoperatively decreases the risk of iatrogenic lung injury. The use of noninvasive positive pressure ventilation (NIV), continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) provides respiratory support when patients are recovering from anesthesia. These strategies provide respiratory support by preventing alveolar collapse in patients who are spontaneously breathing. Contraindications for NIV use include the following:
Patient’s inability to protect their airway
Glasgow coma scale <8
High risk of cardiac arrest
Rapidly progressive neuromuscular weakness
Unable to correctly fit the face mask (facial tumors, facial surgery)
Vomiting or risk of aspiration
Skin breakdown that may be exacerbated by tight-fitting mask
High-Flow Nasal Cannula Therapy
High-flow nasal cannula (HFNC) therapy delivers heated and humidified oxygen via nasal prongs at recommended flow rates of 2–8 L/min for neonates and 4–70 L/min for children. An air-oxygen blender allows the percentage of oxygen delivered to the patient to be adjusted. HFNC is well tolerated in pediatric patients, from neonates through adolescence, and works to improve alveolar oxygen delivery through the generation of PEEP and dead space carbon dioxide washout. The heated and humidified flow prevents airway dryness, which preserves mucociliary function and enhances secretion clearance. Ideally, HFNC decreases the work of breathing and the need to escalate respiratory support to either CPAP or BiPAP and is often better tolerated than positive pressure ventilation with CPAP or BiPAP. HFNC may provide some positive pressure at sufficiently high flows, but this is limited due to multiple variables affecting the transmission of flow to the patient. The ability of HFNC to prevent the need for mechanical ventilation or to prevent mortality has been inconsistently supported in previous studies.
Pulmonary hygiene techniques, including traditional chest physical therapy, use postural drainage, percussion, chest wall vibration, and coughing to assist with airway clearance and maintenance. Postural drainage utilizes gravity to facilitate the movement of secretions from the peripheral airways to the larger bronchi. Percussion loosens secretions from the bronchial walls and can be performed in different positions, supporting postural drainage. Chest wall vibrations loosen or move bronchial secretions similar to percussion, but the clinician’s hand or device does not lose contact with the chest wall. Most sessions last 15–20 min and are scheduled 4–6 times per day. For acutely ill patients, pulmonary hygiene helps combat the hypoxemic effects of atelectasis, ventilation/perfusion mismatch, bronchospasm, or hypoventilation. Contraindications to pulmonary hygiene include increased intracranial pressure (>20 mmHg), spinal injury, active hemoptysis, hemodynamic instability, pulmonary embolism, pulmonary edema with congestive heart failure, or an open wound over the area where chest physiotherapy would be applied.
Physical examination may miss up to half of the patients with early chemotherapy-induced heart failure, primarily due to limitations of echocardiography in diagnosing diastolic dysfunction and right heart failure. Echocardiography is a generally accepted form of evaluating cardiac function, but is better suited for assessing left heart failure. Children at risk for cardiac disease from chemotherapy, especially those previously treated with anthracycline therapy (doxorubicin, daunorubicin, idarubicin, and epirubicin), should have a documented echocardiogram before surgery. Early toxicity can occur within days or weeks of the initial dose of anthracycline.
Pericardial and Pleural Effusions
Cardiac dysfunction from pericardial effusion can progress to cardiac tamponade if left untreated. Pediatric oncology patients at the highest risk for pericardial effusion are those with Hodgkin’s lymphoma or those who have received a hematopoietic stem cell transplant. The reported incidences in these patient populations are 5% to 25% and 0.2% to 16.9%, respectively. Pericardial effusion may occur due to graft versus host disease, infection, or immune suppression. Symptoms include tachycardia, S3, friction rub, narrow pulse pressure, dyspnea, cough, chest pain, electrocardiogram (ECG) changes (low voltage, electrical alternans, ST-segment elevation, or PR depression), pulsus paradoxus, Kussmaul sign (elevated jugular venous pressure with inspiration), and abdominal pain. The majority of pericardial effusions seen in patients with Hodgkin’s lymphoma are clinically silent and resolve with treatment of the underlying malignancy. Monitoring for the progression of pericardial effusion is performed using serial echocardiograms. Moderate to large effusions, as seen with hematopoietic stem cell transplantation, have a greater risk of life-threatening cardiac tamponade and require urgent pericardiocentesis. , Maintaining an appropriate fluid balance is essential for the management of pericardial and pleural effusions. A reduced preload due to under resuscitation could lead to cardiovascular collapse. By contrast, excessive administration of intravascular volume may worsen effusions.
Systemic Inflammatory Response Syndrome
Systemic inflammatory response syndrome (SIRS) is a stress response associated with hyperthermia, hypothermia, leukocytosis, leukopenia, tachycardia, and tachypnea. It is a systemic activation of the innate immune system triggered by infection, trauma, surgery, or other stressors. The degree of inflammation and the severity of the SIRS vary depending on the patient’s situation. The pediatric oncology population, especially hematopoietic stem cell transplant patients, may experience a SIRS after routine surgery.
Postoperative fluid management should consider the type and length of surgery, estimated fluid deficit, ongoing fluid loss, and maintenance fluid requirements. Preoperative dehydration or inadequate intraoperative fluids may manifest as tachycardia, diastolic hypotension, or concentrated urine. Postoperatively, endothelial dysfunction results in capillary leak and may increase the risk of acute renal injury and the accumulation of pleural effusions and ascites. Normal saline solutions, PlasmaLyte, lactated Ringer’s solution, albumin, and blood products may be used for intravascular volume expansion. Although still controversial, albumin and fresh frozen plasma may have added benefits over large crystalloid volume infusion, protecting and repairing vascular endothelium. ,
Postoperative laboratory studies should include a complete blood count, electrolyte levels, albumin, and coagulation studies to determine which fluid would provide the greatest benefit. Once euvolemia is established, intravenous maintenance fluids should be isotonic with appropriate amounts of sodium chloride, potassium chloride, and dextrose to help prevent hyponatremia, hypokalemia, and hypoglycemia. The use of hypotonic fluids in the postoperative period should be restricted to patients with sizeable free water losses, such as neonates and children with diabetes insipidus. In addition, surgical patients are prone to developing the syndrome of inappropriate antidiuretic hormone, leading to hyponatremia and fluid retention. Serum sodium levels should therefore be checked regularly after surgery and corrected appropriately in any patient with a seizure or decreased level of consciousness.
Postoperative hypotension should be treated with intravenous fluids or blood products until euvolemia is established. Early inotropic support should be considered in patients at risk of fluid overload and diastolic dysfunction. Hematopoietic stem cell transplant patients with endothelial damage are prone to a systemic inflammatory response after surgery, and fluid overload is detrimental to their overall survival. These patients may benefit from the inotropic, vasodilator, and lusitropic effects to improve cardiac output. Patients with preexisting preoperative or newly discovered postoperative heart dysfunction on echocardiography may benefit from milrinone’s inotropic and afterload reducing properties. Low-dose epinephrine in combination with milrinone can be used in hypotensive patients with poor contractility. Vasopressin can be used as a vasopressor to elevate systemic vascular resistance and improve organ perfusion. Norepinephrine can be used in patients with cytokine release syndrome or septic shock. Calcium infusions may also be used as inotropic agents in young children. ,
Postoperative agitation is common and may be due to the residual effects of anesthetics, hypoxia, hypercapnia, bladder distention, delirium, or pain. Many children with cancer have been exposed to opioids and narcotics earlier in their treatment plans and may experience pain before their surgical procedures. Pain is often related to anticancer therapies; however, the most painful events are medical procedures or surgery. A patient-specific multimodal pain management plan can be beneficial for patients with pain that is difficult to control before medical procedures or surgery. Both pharmacologic and nonpharmacologic modalities can provide effective and safe pain control. Epidural and regional anesthesia, patient-controlled analgesia (PCA), opioids, ketamine, dexmedetomidine infusions, acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs) gabapentin, and supplemental therapies are often used to provide a holistic approach to pain control.
In the past decade, an emerging concept in cancer surgery was the opioid-sparing analgesic approach with multimodal use of regional analgesia/anesthesia, acetaminophen, NSAIDs, gabapentin, and low-dose ketamine. The growing success of regional anesthesia has led to a decrease in the need for and length of opioid infusions. For example, in one large children’s hospital, local anesthetic infusions via peripheral nerve catheters increased 10-fold over 10 years. In addition, the need for PCA for narcotic delivery has decreased dramatically.
Continuous peripheral nerve blocks are increasingly used in children for postoperative pain control, especially after orthopedic cancer surgeries or extensive tumor resections. These nerve blocks are generally used for a few days, while swelling and pain are the most problematic. Nerve blocks may also be used to relieve intractable pain during end-of-life care. Thoracic surgeries for oncology patients are particularly painful. Nerve blocks have been reported to reduce pain scores, nausea, vomiting, pulmonary complications, and associated stress response markers. In a study involving 204 pediatric patients undergoing minimally invasive surgery, children undergoing thoracic surgery had significantly higher pain scores than those who underwent gastrointestinal surgery. These patients were treated with epidural analgesia and a combination of acetaminophen, morphine, ketorolac, tramadol, and ibuprofen.
PCA is an effective method for intravenous administration of opioids after surgery. The benefit is derived from the lack of a lag time between the demand for medication and its delivery. Most hospitals have protocols for using PCAs with options for continuous infusions, bolus infusions, and nurse and proxy (parent) administration. For example, in a Boston children’s hospital study, 32,338 PCAs were used over a 22-year period with an extremely low (1%) rate of adverse events. In this study, there were only five incidents where patients could administer larger bolus doses of opioids themselves.
Opioids (e.g., morphine, hydromorphone, fentanyl) are the primary medications used to treat postoperative pain. Experimental research in cancer cells and in vivo animal models of cancer suggest that opioids facilitate cancer cell proliferation. However, other studies have demonstrated the opposite effect, reporting an inhibitory effect on cancer cells. Given the problems associated with opioid-related adverse events (ORADEs) opioid-sparing anesthesia (OSA) is gaining popularity in contemporary practice. OSA is administered, using dexmedetomidine, propofol, ketamine, and lidocaine infusions as appropriate; along with non-opioid adjuncts for analgesia utilizing acetaminophen, NSAIDs, gabapentinoids, and regional anesthesia in the absence of contraindications.
Ketamine and Dexmedetomidine
Dexmedetomidine infusions are often used postoperatively in the pediatric intensive care unit to manage pain and anxiety because the drug does not suppress the respiratory drive. The side effects of dexmedetomidine commonly include bradycardia and hypotension. Additionally, ketamine infusion provides sedation and pain control. One study in adults showed that low-dose continuous infusion of ketamine in mechanically ventilated patients was associated with a significant decrease in opioid use without adversely affecting hemodynamic stability.
Nerve pain is prominent in pediatric patients who have undergone leg amputation for osteosarcoma, Ewing sarcoma, or in patients with chemotherapy-induced peripheral neuropathy. Patients often complain of a burning, gnawing, or stabbing sensation of the limbs. Phantom nerve pain typically occurs within the first week following surgery and is present in up to 92% of pediatric patients in the first year. Phantom nerve pain is often treated with narcotics, gabapentin, tricyclic antidepressants, opiates, nerve blocks, and epidural catheters. In addition, mirror therapy, psychotherapy, and acupuncture have been successfully used to treat phantom nerve pain. , In a prospective, double-blind, randomized controlled trial, preoperative administration of gabapentin was associated with reduced pain scores in the postoperative period. Adding opioids postoperatively further reduces postoperative pain levels. Nerve pain is often challenging to treat. The benefits of a combination of therapies were demonstrated in a case study of a patient with significant preoperative opioid use undergoing a hemipelvectomy and hip disarticulation, where phantom pain was managed with a multimodal strategy of opioids, ketamine, gabapentin, clonidine, epidural, psychologic, and cognitive behavioral therapy, with a reduction in immediate postoperative pain that completely resolved over 2 years.