Anesthetic considerations for the pediatric oncology patient - Part 3: pain, cognitive dysfunction, and preoperative evaluation

Abstract

In part three of this three-part review, we continue with discussion of the effects of tumor and its therapy as they impact neurocognitive functioning, psychosocial issues of the patient and family, and the mechanisms and experience of pain in the child with cancer. A discussion of preanesthetic testing and evaluation in this patient population is next presented for the reader, focusing on the factors which pose the commonest and greatest risks to the child undergoing surgery. Lastly, an algorithmic approach to evaluating and managing key components of the medical history of pediatric patients is presented.

The new challenging pediatric patient

“…Is there any increased risk for neurotoxicity or block failure (caused by arachnoiditis)? Using a specific preoperative checklist, proposed by Latham et al (6), is probably the best and safest way to address all the potential consequences of previous cancer therapy in a paucisymptomatic patient.…”

Anterior mediastinal masses in children

“…The patient may need early preoperative assessment in order to assess the biochemistry, haematology, and coagulation profiles and allow for the potential correction of abnormalities or preemptive ordering of blood products. 10 Nitrous oxide impairs methionine synthetase activity, which disturbs folate metabolism and therefore vitamin B12 metabolism. Prolonged exposure to nitrous oxide is associated with bone marrow suppression.…”

“…14 Consideration should be made for potential coagulopathy associated with malignancies. 10 Airway compromise may be severe even under sedation.…”

Perioperative management in children with chronic pain

“…Oncological pain may be due to acute tissue or bony invasion, inflammation, neuropathic pain, related to procedures or treatments, or a combination of causes . Children may have significant psychological distress due to multiple major physical and psychological traumas they have experienced during the course of their condition . Low‐dose oral midazolam has been shown to reduce fear and distress during needle procedures .…”

“…Inclusion of child life specialists, hypnosis, distraction, and imagery may be effective as adjuncts to pharmacological interventions in managing procedure related pain, anxiety, and distress . Many children and parents have developed a specific routine during the perioperative period and the anesthesiologist should attempt to honor and respect their preferences . Effective treatment includes multimodal analgesia as many patients may be opioid‐tolerant.…”