Preoperative Evaluation of the Cancer Patient for Emergency Surgery

  • Russell J. Gray
  • Michael W. Lew


In cancer surgical emergencies there are aspects of the disease and treatment that may complicate management and require special attention. Oncologic surgical emergencies may be related to the cancer itself, namely invasion by the tumor (i.e., gut, airway or vascular obstruction, or brain mass lesions), or complications as a result of cancer care, such as chemotherapy, immunotherapy, or radiation (i.e., perforation, infection). Optimal medical care enhanced by effective communication between all care providers, including oncologic, medical, surgical, and anesthesia teams, is hoped to improve patient outcomes and reduce perioperative complications.


Preoperative evaluation Cardiac risk Surgical risk calculator Emergency surgery Coronary stents Goal-directed therapy Pulmonary risk Difficult airway Obstructive sleep apnea Sepsis 


  1. 1.
    Miller RD. Miller’s anesthesia. 8th ed. Philadelphia: Elsevier; 2015.Google Scholar
  2. 2.
    Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audisio RA. Surgical considerations in older adults with cancer. J Clin Oncol. 2014;32(24):2647–53. doi: 10.1200/JCO.2014.55.0962.CrossRefPubMedGoogle Scholar
  3. 3.
    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215–45. doi: 10.1161/CIR.0000000000000105.CrossRefPubMedGoogle Scholar
  4. 4.
    Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Davis C, Tait G, Carroll J, Wijeysundera DN, Beattie WS. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can J Anaesth. 2013;60(9):855–63. doi: 10.1007/s12630-013-9988-5.CrossRefPubMedGoogle Scholar
  6. 6.
    Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, Cohen ME. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42. doi: 10.1016/j.jamcollsurg.2013.07.385. e831–3.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Girish M, Trayner Jr E, Dammann O, Pinto-Plata V, Celli B. Symptom-limited stair climbing as a predictor of postoperative cardiopulmonary complications after high-risk surgery. Chest. 2001;120(4):1147–51.CrossRefPubMedGoogle Scholar
  8. 8.
    Sonny A, Gornik HL, Yang D, Mascha EJ, Sessler DI. Lack of association between carotid artery stenosis and stroke or myocardial injury after noncardiac surgery in high-risk patients. Anesthesiology. 2014;121(5):922–9. doi: 10.1097/ALN.0000000000000438.CrossRefPubMedGoogle Scholar
  9. 9.
    Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology. 2011;114(6):1289–96. doi: 10.1097/ALN.0b013e318216e7f4.CrossRefPubMedGoogle Scholar
  10. 10.
    Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936–44. doi: 10.1161/CIRCULATIONAHA.108.828228.CrossRefPubMedGoogle Scholar
  11. 11.
    Shah KB, Kleinman BS, Rao TL, Jacobs HK, Mestan K, Schaafsma M. Angina and other risk factors in patients with cardiac diseases undergoing noncardiac operations. Anesth Analg. 1990;70(3):240–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Ashton CM, Petersen NJ, Wray NP, Kiefe CI, Dunn JK, Wu L, Thomas JM. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med. 1993;118(7):504–10.CrossRefPubMedGoogle Scholar
  13. 13.
    Chong CP, Lam QT, Ryan JE, Sinnappu RN, Lim WK. Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age Ageing. 2009;38(2):168–74. doi: 10.1093/ageing/afn231.CrossRefPubMedGoogle Scholar
  14. 14.
    Cahill TJ, Bowes P, Duncan E, Drye E, Sen S, Miller C, Reshamwalla S, Andrew C, Ward M, Bakhai A. Risk stratification by cardiac biomarkers following emergency gastrointestinal surgery. ISRN Vasc Med. 2011;2011:5. doi: 10.5402/2011/403130.Google Scholar
  15. 15.
    Barash P, Akhtar S. Coronary stents: factors contributing to perioperative major adverse cardiovascular events. Br J Anaesth. 2010;105 Suppl 1:i3–15. doi: 10.1093/bja/aeq318.CrossRefPubMedGoogle Scholar
  16. 16.
    Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O’Gara PT, Sabatine MS, Smith PK, Smith SC, Jr (2016) 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation. doi: 10.1161/CIR.0000000000000404.
  17. 17.
    Wijeysundera DN, Wijeysundera HC, Yun L, Wąsowicz M, Beattie WS, Velianou JL, Ko DT. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation. 2012;126(11):1355–62. doi: 10.1161/circulationaha.112.102715.CrossRefPubMedGoogle Scholar
  18. 18.
    Sharma AK, Ajani AE, Hamwi SM, Maniar P, Lakhani SV, Waksman R, Lindsay J. Major noncardiac surgery following coronary stenting: when is it safe to operate? Catheter Cardiovasc Interv. 2004;63(2):141–5. doi: 10.1002/ccd.20124.CrossRefPubMedGoogle Scholar
  19. 19.
    Hammill BG, Curtis LH, Bennett-Guerrero E, O’Connor CM, Jollis JG, Schulman KA, Hernandez AF. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology. 2008;108(4):559–67. doi: 10.1097/ALN.0b013e31816725ef.CrossRefPubMedGoogle Scholar
  20. 20.
    Hernandez AF, Whellan DJ, Stroud S, Sun JL, O'Connor CM, Jollis JG. Outcomes in heart failure patients after major noncardiac surgery. J Am Coll Cardiol. 2004;44(7):1446–53. doi: 10.1016/j.jacc.2004.06.059.CrossRefPubMedGoogle Scholar
  21. 21.
    Kazmers A, Cerqueira MD, Zierler RE. Perioperative and late outcome in patients with left ventricular ejection fraction of 35% or less who require major vascular surgery. J Vasc Surg. 1988;8(3):307–15.CrossRefPubMedGoogle Scholar
  22. 22.
    Mourad M, Chow-Chine L, Faucher M, Sannini A, Brun JP, de Guibert JM, Fouche L, Lambert J, Blache JL, Mokart D. Early diastolic dysfunction is associated with intensive care unit mortality in cancer patients presenting with septic shock. Br J Anaesth. 2014;112(1):102–9. doi: 10.1093/bja/aet296.CrossRefPubMedGoogle Scholar
  23. 23.
    Groban L, Butterworth J. Perioperative management of chronic heart failure. Anesth Analg. 2006;103(3):557–75. doi: 10.1213/01.ane.0000226099.60493.d9.CrossRefPubMedGoogle Scholar
  24. 24.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin III JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt III TM, Thomas JD, Members AATF. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(23):e521–643. doi: 10.1161/CIR.0000000000000031.CrossRefPubMedGoogle Scholar
  25. 25.
    Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F, Klein J, Roelandt JR, Poldermans D. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med. 2004;116(1):8–13.CrossRefPubMedGoogle Scholar
  26. 26.
    Andersson C, Jorgensen ME, Martinsson A, Hansen PW, Gustav Smith J, Jensen PF, Gislason GH, Kober L, Torp-Pedersen C. Noncardiac surgery in patients with aortic stenosis: a contemporary study on outcomes in a matched sample from the Danish health care system. Clin Cardiol. 2014;37(11):680–6. doi: 10.1002/clc.22324.CrossRefPubMedGoogle Scholar
  27. 27.
    Movahed MR, Ahmadi-Kashani M, Kasravi B, Saito Y. Increased prevalence of mitral stenosis in women. J Am Soc Echocardiogr. 2006;19(7):911–3. doi: 10.1016/j.echo.2006.01.017.CrossRefPubMedGoogle Scholar
  28. 28.
    Mittnacht AJ, Fanshawe M, Konstadt S. Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth. 2008;12(1):33–59. doi: 10.1177/1089253208316442.CrossRefPubMedGoogle Scholar
  29. 29.
    Grocott MP, Dushianthan A, Hamilton MA, Mythen MG, Harrison D, Rowan K, Optimisation Systematic Review Steering Group. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Br J Anaesth. 2013;111(4):535–48. doi: 10.1093/bja/aet155.CrossRefPubMedGoogle Scholar
  30. 30.
    Grocott MP, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg. 2005;100(4):1093–106. doi: 10.1213/01.ANE.0000148691.33690.AC.CrossRefPubMedGoogle Scholar
  31. 31.
    Suehiro K, Joosten A, Alexander B, Cannesson M. Guiding goal-directed therapy. Curr Anesthesiol Rep. 2014;4:360–75. doi: 10.1007/s40140-014-0074-5.CrossRefGoogle Scholar
  32. 32.
    Kumar A, Anel R, Bunnell E, Habet K, Zanotti S, Marshall S, Neumann A, Ali A, Cheang M, Kavinsky C, Parrillo JE. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004;32(3):691–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172–8. doi: 10.1378/chest.07-2331.CrossRefPubMedGoogle Scholar
  34. 34.
    Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006;97(6):755–7. doi: 10.1093/bja/ael290.CrossRefPubMedGoogle Scholar
  35. 35.
    Funk DJ, Moretti EW, Gan TJ. Minimally invasive cardiac output monitoring in the perioperative setting. Anesth Analg. 2009;108(3):887–97. doi: 10.1213/ane.0b013e31818ffd99.CrossRefPubMedGoogle Scholar
  36. 36.
    Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311(21):2181–90. doi: 10.1001/jama.2014.5305.CrossRefPubMedGoogle Scholar
  37. 37.
    Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B, Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012;157(1):49–58. doi: 10.7326/0003-4819-157-1-201206190-00429.CrossRefPubMedGoogle Scholar
  38. 38.
    Cata JP. Perioperative anemia and blood transfusions in patients with cancer: when the problem, the solution, and their combination are each associated with poor outcomes. Anesthesiology. 2015;122(1):3–4. doi: 10.1097/ALN.0000000000000518.CrossRefPubMedGoogle Scholar
  39. 39.
    Eissa D, Carton EG, Buggy DJ. Anaesthetic management of patients with severe sepsis. Br J Anaesth. 2010;105(6):734–43. doi: 10.1093/bja/aeq305.CrossRefPubMedGoogle Scholar
  40. 40.
    Fagley RE. Anesthetic care of septic patients. Adv Anesth. 2014;32(1):191–203. doi: 10.1016/j.aan.2014.08.003.CrossRefGoogle Scholar
  41. 41.
    Campbell GA, Hu D, Okusa MD. Acute kidney injury in the cancer patient. Adv Chronic Kidney Dis. 2014;21(1):64–71. doi: 10.1053/j.ackd.2013.08.002.CrossRefPubMedGoogle Scholar
  42. 42.
    Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, Surviving Sepsis Campaign Guidelines Committee Including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637. doi: 10.1097/CCM.0b013e31827e83af.CrossRefPubMedGoogle Scholar
  43. 43.
    Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768–75. doi: 10.1093/bja/aes022.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth. 2012;109(6):897–906. doi: 10.1093/bja/aes308.CrossRefPubMedGoogle Scholar
  45. 45.
    Meyer S, McLaughlin VV, Seyfarth HJ, Bull TM, Vizza CD, Gomberg-Maitland M, Preston IR, Barbera JA, Hassoun PM, Halank M, Jais X, Nickel N, Hoeper MM, Humbert M. Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey. Eur Respir J. 2013;41(6):1302–7. doi: 10.1183/09031936.00089212.CrossRefPubMedGoogle Scholar
  46. 46.
    Barnett CF, Machado RF. Sildenafil in the treatment of pulmonary hypertension. Vasc Health Risk Manag. 2006;2(4):411–22.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Rockwood K, Abeysundera MJ, Mitnitski A. How should we grade frailty in nursing home patients? J Am Med Dir Assoc. 2007;8(9):595–603. doi: 10.1016/j.jamda.2007.07.012.CrossRefPubMedGoogle Scholar
  48. 48.
    Tsiouris A, Horst HM, Paone G, Hodari A, Eichenhorn M, Rubinfeld I. Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality. J Surg Res. 2012;177(1):1–6. doi: 10.1016/j.jss.2012.02.048.CrossRefPubMedGoogle Scholar
  49. 49.
    Inagaki J, Rodriguez V, Bodey GP. Proceedings: causes of death in cancer patients. Cancer. 1974;33(2):568–73.CrossRefPubMedGoogle Scholar
  50. 50.
    Cook TM, Woodall N, Frerk C, Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617–31. doi: 10.1093/bja/aer058.CrossRefPubMedGoogle Scholar
  51. 51.
    American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98(5):1269–77.CrossRefGoogle Scholar
  52. 52.
    Ramachandran SK, Mathis MR, Tremper KK, Shanks AM, Kheterpal S. Predictors and clinical outcomes from failed Laryngeal Mask Airway Unique: a study of 15,795 patients. Anesthesiology. 2012;116(6):1217–26. doi: 10.1097/ALN.0b013e318255e6ab.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of AnesthesiologyCity of HopeDuarteUSA

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