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Year : 2018  |  Volume : 62  |  Issue : 6  |  Page : 470-472  

Brachytherapy implant insertion in head-and-neck cancer: Results of anaesthetic technique at a tertiary care hospital


Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Satyen Parida
Department of Anesthesiology and Critical Care, JIPMER, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_206_18

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How to cite this article:
Ambasta S, Parida S, Rudingwa P, Mishra SK. Brachytherapy implant insertion in head-and-neck cancer: Results of anaesthetic technique at a tertiary care hospital. Indian J Anaesth 2018;62:470-2

How to cite this URL:
Ambasta S, Parida S, Rudingwa P, Mishra SK. Brachytherapy implant insertion in head-and-neck cancer: Results of anaesthetic technique at a tertiary care hospital. Indian J Anaesth [serial online] 2018 [cited 2018 Sep 20];62:470-2. Available from: http://www.ijaweb.org/text.asp?2018/62/6/470/234012




   Introduction Top


Recent technologic advances have enabled high-dose rate and pulsed-dose rate brachytherapy techniques to minimise radiation exposure hazards while offering the physical and biological advantages of brachytherapy.[1] Brachytherapy implant insertion procedures present the anaesthesiologist with numerous challenges since patients are often elderly with coincidental diseases. Second, the implant insertion procedures are extremely painful and require both analgesia and immobilisation. Third, the patients presenting for these procedures for head-and-neck cancers have a very high incidence of difficult airways. This study intends to review the anaesthesia records of 32 procedures of brachytherapy for head-and-neck cancer over a period of 2 years and report the experience at the author's institution.


   Methods Top


This was a retrospective study conducted from July 2014 to July 2016 after approval from the Institute Ethics Committee, following which data were collected from the existing anaesthetic records. The patient data, process times and data on anaesthetic management were recorded. These included age, sex, height, weight, the American Society of Anaesthesiologists (ASA) status, Body Mass Index (BMI), history of previous surgery or brachytherapy episodes, localisation of cancer, duration of procedure including anaesthesia time in minutes, type of anaesthesia administered, type of airway devices used and anaesthesia-related complications. All data are presented as mean, median or proportions as appropriate.


   Results Top


The data of 32 patients were retrieved retrospectively. Mean age was 55 ± 14.2 years and BMI was 23.6 ± 6.2 kg/m 2. Four patients had an ASA physical status of I, 17 ASA II, 9 ASA III and the remaining two ASA IV. Most patients had modified Mallampatti (MMP) Grade II (87.5%), whereas one had MMP Grade 4.

The localisation of tumours is shown in [Table 1]. Nearly 81% of the cases were done under balanced general anaesthesia. General anaesthesia was induced with thiopentone sodium, and muscle relaxation provided with succinylcholine (29.6%), vecuronium (36%) or atracurium (33.3%). Fentanyl was used for intra-operative analgesia in all cases, whereas 18.5% of the patients received IV morphine in addition. Four carcinoma lip cases were managed with local anaesthesia infiltration and sedation with propofol and ketamine. One case of upper lip cancer was managed with infra-orbital nerve block combined with sedation with propofol and ketamine. The airway management techniques employed for patients subjected to GA are shown in [Table 2]. More than 80% intubations were achieved in the first attempt. Airway adjuncts such as stylets and bougies were used in 19% of patients each. One patient had a tracheostomy in situ.
Table 1: Localization of the treated tumours in relation to the number of patients

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Table 2: Airway management techniques according to the localization of the tumour treated

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Post-operative analgesia was provided for the carcinoma lip cases with intravenous (iv) paracetamol. All other cases (84.4%) received iv tramadol and paracetamol. Some patients also received oral diclofenac (31.2%) and iv morphine (37.5%) when required.

The mean duration of the procedures was 90 ± 60 min, of which 70 ± 49 min was used for the actual brachytherapy needle insertion procedure (maximum duration of the procedure was 105 min). The two most common complications were post-operative nausea and vomiting (28.12%) and delayed recovery (21.8%). No patient showed SpO2<95% at any time during airway management; although, there were two episodes (6.25%) of laryngospasm at extubation, which were expeditiously managed. None of the patients developed immediate complications in terms of bleeding at the implant site during insertion of catheters. All patients were extubated on the operating table except the patient with a preoperative tracheostomy.


   Discussion Top


The study data identify the proportion of high-risk patients, characterise airway management procedures and complications of interventions as well as incorporate duration of procedures and type of anaesthesia. The anaesthetic procedure of choice was balanced general anaesthesia with endotracheal intubation, and we report a particularly high proportion of nasal intubations. Brachytherapy implant insertion was undertaken in all age groups from young, otherwise healthy adults to the elderly with important concomitant morbidity. Other case reports published suggest that even small children are treated by brachytherapy to reduce radiation-induced complications.[2],[3]

Keeping in mind the reported high incidences of difficult intubations, the difficult airway cart was kept ready, as has been described in earlier studies.[4] In the study of 20 patients of the head-and-neck implant by Sanghavi, two developed bronchospasm and in six patients tracheostomy needed to be done.[4] Peyyety and Saxena [5] in their study of anaesthetic implications of brachytherapy for the head-and-neck cancer patients had a high incidence of disease-related malnutrition and oncotherapy related nausea, vomiting and loss of appetite. Our data on general anaesthesia shows that most standard techniques could be employed for these patients. Anaesthetics and analgesics embracing the entire spectrum of short-acting drugs were used as per necessity. As there is a lack of prior investigations, we cannot determine if our clinical execution could be considered the standard way of managing anaesthesia for brachytherapy. In a retrospective review of 18 patients, Lim et al.[6] concluded that GA has more complications as compared to monitored anaesthesia care. Our data do not reinforce the importance of any special anaesthetic regimen. No untoward outcome was observed in our patients. General anaesthesia was administered in > 81% of these implant surgeries, although a few cases of carcinoma lip were done under local anaesthesia infiltration or regional blocks and sedation.

Post-operatively, all patients were observed for respiratory obstruction for 2 h and shifted to treatment room. Care was given for Ryle's tube, tracheostomy tube, hydration of patients, provision of analgesics and antibiotics as suggested in previous literature.[4] Our data indicate that ASA III and IV patients comprised about 34% of all anaesthetic procedures carried out in head-and-neck cancers for brachytherapy implant insertion.

The limitations of our study include the number of cases which are very less to conclude about the patient safety aspects of their perioperative management. Furthermore, we just presented one approach to handle the cases without comparing it to alternative management strategies.


   Conclusion Top


In summary, the presented concept permits a possible approach to the anaesthetic management for brachytherapy implant insertion in head-and-neck cancer patients. It needs caution on the part of the anaesthesiologist. It starts with the anaesthesiologist forming a reasonable pre-operative opinion about the airway, optimising systemic diseases, devising stratagems for excellent pain relief both intra- and post-operatively and appropriate monitoring of patient vitals throughout. The complications of the procedure are linked to close clinical supervision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Roessler B, Six LM, Gustorff B. Anaesthesia for brachytherapy. Curr Opin Anaesthesiol 2008;21:514-8.  Back to cited text no. 1
[PUBMED]    
2.
Gustorff B, Lierz P, Felleiter P, Knocke TH, Hoerauf K, Kress HG, et al. Ropivacaine and bupivacaine for long-term epidural infusion in a small child. Br J Anaesth 1999;83:673-4.  Back to cited text no. 2
    
3.
Kozek-Langenecker SA, Marhofer P, Sator-Katzenschlager SM, Dieckmann K. S(+)-ketamine for long-term sedation in a child with retinoblastoma undergoing interstitial brachytherapy. Paediatr Anaesth 2005;15:248-50.  Back to cited text no. 3
[PUBMED]    
4.
Sanghavi PR. Anaesthetic implication for brachytherapy for head and neck cancer patients. J Anaesth Clin Pharmacol 2004;20:147-51.  Back to cited text no. 4
    
5.
Peyyety JS, Saxena A. Anaesthetic implications of brachytherapy for head and neck cancer patients, a retrospective analysis. J Anaesth Clin Pharmacol 1998;14:363-8.  Back to cited text no. 5
    
6.
Lim KH, Lu JJ, Wynne CJ, Back MF, Mukherjee R, Razvi K, et al. A study of complications arising from different methods of anesthesia used in high-dose-rate brachytherapy for cervical cancer. Am J Clin Oncol 2004;27:449-51.  Back to cited text no. 6
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    Tables

  [Table 1], [Table 2]



 

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