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Current Anaesthesia & Critical Care (2008) 19, 50–58

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FOCUS ON: ONCOLOGY

Anaesthesia and paediatric oncology

Philippa Evans, David Chisholm�

The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK

KEYWORDSAnaesthesia;Paediatric;Cancer;Oncology;Chemotherapy;Radiotherapy

ee front matter & 2007acc.2007.07.012

ing author. Tel.: +44 202 9756.ess: david.chisholm@rm

Summary Children with cancer present unique challenges to all concerned withtheir management. The disease process and its treatment can have a profoundimpact on the patient’s physiological and psychological state. Anaesthetists areoften involved in the diagnosis, treatment and emergency resuscitation of thesepatients.

This article aims to review the anaesthetic issues associated with childhoodmalignancy and the increasing role played by the anaesthetist as part of themultidisciplinary team caring for these children. There is particular focus on theanaesthetic techniques used for radiotherapy and short painful procedures withinthis patient population.& 2007 Elsevier Ltd. All rights reserved.

Introduction

In the UK there are about 1500 new cases ofchildhood cancer diagnosed each year. Canceraccounts for about 20% of the deaths in childrenaged 1–14 years1 and one third of all childhoodcancers are leukaemias. Acute lymphoblastic leu-kaemia (ALL) is by far the most common represent-ing 80% of all childhood leukaemias and 25% of allchildhood cancers. It commonly occurs between 1and 6 years with a peak incidence at 2–3 years.Lymphomas are much less common and account forless than 10% of childhood cancers. Brain and spinaltumours account for 25% of childhood cancers.These are most commonly astrocytomas, primitiveneuroectodermal tumours and ependymomas. Em-

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bryonal tumours make up about 15% of childhoodcancers. These tumours arise due to proliferationof tissue normally only seen in the developingembryo and include: medulloblastoma, neuroblas-toma (proliferation of sympathetic nervous systemtissues), retinoblastoma, Wilm’s tumour (nephro-blastoma), hepatoblastoma and embryonal rhabdo-myosarcoma in soft tissue. Rarer cancers includebone tumours, soft tissue sarcomas and germ celland gonadal tumours.

Cancer is about one fifth more common in boys.Childhood cancers have a much better response andsurvival rate than adult cancers. Overall the 5-yearsurvival rate is about 75% this increases to around80% in ALL. Chemotherapy, radiotherapy andsurgery are the principle methods used in thetreatment of cancer. Surgery may be in the form ofcurative resection or tumour debulking. Cytotoxicdrugs target tumour cells throughout the body.They damage DNA through a variety of mechanisms,

d.

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Anaesthesia and paediatric oncology 51

causing cell death or preventing cell replication.They are classified according to their mode ofaction but have certain side effects in commonwhich include myelosuppression, nausea and vo-miting, and alopecia.

Radiotherapy provides local disease control andcan provide synergistic cytotoxicity when used incombination with chemotherapy. Radiotherapygenerates free radicals that damage DNA thusinterfering with cell function. Well vascularisedand oxygenated tissues are more sensitive as theyhave a rich oxygen supply for free radical forma-tion. Rapidly proliferating tissues are more suscep-tible, for example skin and mucosa, which accountsfor the common side effects of local erythema anddesquamation. Radiotherapy is used as a primarytherapy, as an adjuvant or neoadjuvant therapyeither alone or in combination with chemotherapy,and also in the setting of symptom palliation.

Anaesthetic implications of childhoodcancer

The disease process itself may have implications forthe anaesthetist. This is dependent on the diseasetype and its site of presentation. A thorough historyand examination is extremely important for allpaediatric cancer patients. Particular emphasis shouldbe placed on the anatomical effects of the cancer. Alsothe systemic effects of the cancerous process must beconsidered and appropriately investigated.

Airway pathology

Tumours directly involving the airway are relativelyrare in children. However enlarged tonsils andadenoids secondary to leukaemic infiltration arequite common. These may cause obstructive sleepapnoea with the associated anaesthetic problems.Cervical adenopathy can be large enough to causeairway comprise and leukaemic infiltration ofretropharyngeal lymph nodes may present asstridor. Immunocompromised children may alsopresent with opportunistic infections of the upperairway causing life-threatening airflow obstruction.Mucositis associated with chemotherapy may causebleeding and painful blistered mucosa within theoral cavity. The injury to the digestive mucosaextends throughout the gut hence intestinal moti-lity maybe affected. There has been a report ofhyperkalaemia with suxamethonium use in apatient with extensive mucositis. The proposedmechanism is similar to the hyperkalaemic re-sponse seen in thermal injures.2

Mediastinal pathology

One of the most significant oncological anaestheticproblems is the child that has a mediastinal mass.Hodgkin’s lymphoma, T-cell ALL and T-cell non-Hodgkin’s lymphoma can have massive anteriormediastinal masses at presentation. Masses in theanterior mediastinum can cause severe tracheo-bronchial compression. There may also be com-pression of the heart and great vessels (see Fig. 1).The compression of the trachea may extend wellbelow the level of the carina hence endotrachealintubation may not be sufficient to by-pass theobstruction. The induction of anaesthesia in suchcircumstances can lead to complete airway ob-struction, reduction or loss of cardiac output whichmay not be treatable. There are numerous reportsof sudden death under anaesthesia in such pa-tients.3,4

These children may be completely asymptomatichence a screening chest radiograph should beperformed in all children prior to anaesthesia. If amass is seen a CT scan of the chest should beperformed if possible. Studies comparing thedegree of tracheal compression with the incidenceof airway complication have led to the recommen-dation that anaesthesia be avoided in thosepatients with tracheal areas less than 50% ofpredicted. Echocardiography and ultrasound scan-ning are valuable in the assessment of myocardialand great vessel compression and also the presenceof pericardial effusions.5,6

Children with large anterior mediastinal massesshould only be anaesthetised in centres withpaediatric cardiothoracic services. There may bea need for emergency rigid bronchoscopy, tra-cheostomy, thoracotomy or median sternotomy.There should be the capability to perform femor-al–femoral bypass.7 Often it is possible to establisha diagnosis from peripheral blood films, pleuralfluid aspirate or bone marrow aspirate. If this is notpossible it may well be safer for these children tostart treatment prior to tissue diagnosis in order toreduce the tumour mass. The type of treatmentgiven is guided by the most likely diagnosis giventhe patient’s age and the radiographic appearanceof the mass. These masses will often regressextremely quickly following the commencementof chemotherapy and anaesthesia may be providedmore safely within a few days.

Abdominal pathology

Wilm’s tumours and abdominal neuroblastomas canbe massive at presentation. They can cause

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Figure 1 This is the chest radiograph and chest CTscan of a 6-year old child with a new diagnosis of acute lymphoblasticleukaemia (T-ALL). There is a large anterior mediastinal mass causing tracheal compression with extension beyond thecarina to compress the major bronchi.

P. Evans, D. Chisholm52

diaphragmatic splinting making ventilation underanaesthesia problematic. Despite being of nearnormal weight these children are often quitecachectic due to these tumours. All abdominalpathology as well as chemotherapy may havedetrimental effects on gastric emptying.

Intracranial pathology

Supratentorial brain tumours may be associatedwith raised intracranial pressure with all its

implications for the anaesthetist. Leukaemic infil-tration of the meninges may cause marked increasein intracranial pressure.

Systemic effects of cancer

Anaemia is one of the most common problemsencountered in children with cancer. It can lead toreduced oxygen delivery to the tissues. Haemoglo-bin levels above 7 g/dL are usually adequate ifnormal cardiovascular compensatory mechanisms

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exist. However, children may not be able tocompensate if they have chemotherapy-inducedmyocardial dysfunction.

Cancer can have a number of effects oncoagulation and while these may not have directanaesthetic implications, they may need correctionprior to any invasive procedures performed byoncologists or surgeons. Disseminated intravascularcoagulation (DIC) is present in up to 15% of patientswith malignancy.8 It is due to a generalisedactivation of the coagulation system. It morecommonly takes on a chronic form which isasymptomatic and associated with modest reduc-tions in platelet count and fibrinogen levels, andincreased fibrinogen degradation products withminimal changes to prothrombin time or activatedpartial thromboplastin time. The acute form israrer but can be associated with life-threateninghaemorrhage or thrombosis. This is particularlyseen in acute promyelocytic leukaemia (AML-M3).9

Aspariginase a chemotherapy agent used in remis-sion induction for acute leukaemia may also causeDIC. Platelet disorders-both quantitative and qua-litative-can be secondary to myelosuppression ascomplications of chemotherapy or radiotherapy, ordue to extensive bone marrow involvement by thedisease process itself. This can often be exacer-bated by a reduction in clotting factor productioneither due to liver involvement or vitamin Kdeficiency.

Neuroblastomas can secrete cathecholaminesand cause systemic hypertension. Surges in bloodpressure are associated with abdominal palpation.Wilm’s tumours can extend into the inferior venacava and the renal vein leading to renovasculardisorders and systemic hypertension

Cytotoxic agents and radiotherapy

Both chemotherapy and radiotherapy have a vastarray of adverse effects. Those causing cardiac andpulmonary toxicity are of particular relevance tothe anaesthetist.10,11

Cardiac toxicity

Cardiotoxic syndromes associated with cytotoxicagents include: myocardial depression, myocardialischaemia, hypotension, hypertension, myocardi-tis, endomyocardial fibrosis and arrhythmias. Thecommonly implicated drugs are doxorubicin (Adria-mycin), daunorubicin, fluorouracil and cyclopho-sphamide.12,13

The anthracycline class of drugs which includedoxorubicin and daunorubicin are associated with

the most problems. They can cause acute rhythmand conduction disturbances such as supraventri-cular tachycardias and heart block and are alsoassociated with a chronic cardiomyopathy. Childrenand adolescents with previous anthracycline treat-ment and normal cardiac function at rest have beenseen to have certain changes in function underanaesthesia. These changes include decreased infractional shortening, a marker of left-ventricularsystolic function, and stroke–volume index. De-layed cardiotoxicity, sometimes years later, hasbeen seen after anthracycline therapy. A number ofrisk factors predispose a patient to cardiotoxicity.These include cumulative drug dose, total dose onany given day of treatment, rate and route ofadministration, drug combination and dosing sche-dule. Patient factors include age less than 1 year,previous anthracycline chemotherapy, previous orcurrent mediastinal radiation, history of pre-existingcardiovascular disorders and electrolyte abnormali-ties particularly hypokalaemia and hypomagnesae-mia. Children receiving cardiotoxic chemotherapyshould have surveillance echocardiography bothduring and after treatment. It is very useful to havethis information available prior to anaesthesia.

Radiation therapy to the thorax can damage thepericardium, myocardium, heart valves and coro-nary vessels. The risk is increased with concomitantdoxorubicin therapy. Radiation-induced pericardialdisease with pericarditis or effusion, can developfrom 2 months to years after treatment.

Pulmonary toxicity

The adverse respiratory effects of cytotoxic agentscan be early or late in onset. Early complicationsinclude interstitial pneumonitis (methotrexate,bleomycin, paclitaxel), acute non-cardiogenic pul-monary oedema (bleomycin, interleukin-2), bron-chospasm (vinblastine, methotrexate) and pleuraleffusion (methotrexate). Late onset disease is morecommon and usually manifests as pulmonary fibrosis(bleomycin, mitomycin, bulsulfan).

Bleomycin is of particular importance as it resultsin toxicity in approximately 10% of patients. Up to70% of children treated with bleomycin for rhabdo-myosarcoma demonstrate significant restrictivechanges on pulmonary function tests (PFTs). Bleo-mycin can lead to broncholitis obliterans withorganising pneumonia (BOOP), eosinophilic hyper-sensitivity and more commonly bleomycin-inducedpneumonitis (BIP) which can progress to pulmonaryfibrosis. BIP presents with progressive dyspnoea,basal crackles, bilateral infiltrates on chest X-rayand a restrictive pattern on PFTs. It is a diagnosis of

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exclusion once infection, metastasis and lymphan-gitis have been discounted. Treatment is to stop theagent and give steroids.14

The risk of bleomycin-induced lung damage isincreased by increasing total drug dose, thepresence of renal failure and radiation therapy.There is some evidence to suggest that the damageproduce is exacerbated by the administration ofsupplemental oxygen as bleomycin-associated lunginjury is mediated via oxidant pathways. Highfractions of inspired oxygen can provoke lung injurymany years after drug exposure. It is important tomaintain concentrations of inspired oxygen as lowas is safely possible in patients with a history ofbleomycin therapy.

Radiation-induced pulmonary injury manifests asradiation-induced pneumonitis. Its severity is re-lated to the total volume of lung exposed totreatment, the total dose and the size of theindividual fractions of dose. Risk factors includeconcurrent or previous chemotherapy, previousradiotherapy and the withdrawal of steroids. Ithas a worse prognosis the earlier the onset.15

Certain agents can have effects on renal andhepatic function. These should be monitoredthroughout the duration of treatment. Non-steroi-dal anti-inflammatory drugs should be avoided inpatients receiving nephrotoxic chemotherapy.

Tumour lysis syndrome

This syndrome can occur as a result of massivetumour breakdown when treatment is first in-itiated. It has also been reported to occurspontaneously during surgery in untreated patientswith massive lymphoproliferative tumours.16,17 Itmust be considered when anaesthesia is beingconducted early in the treatment schedule. Tumourlysis syndrome most commonly occurs with high-grade lymphomas and acute leukaemias. It must beremembered that steroids have potent anti-cancerproperties, hence the inadvertent administrationof steroids to these patients must be avoided. Thesyndrome results from the sudden release ofintracellular contents into the systemic circulationwhen there is rapid destruction of tumour cells.Metabolic derangements include hyperkalaemia,hypocalcaemia, hyperuricaemia and hyperphospa-hataemia. These can lead to renal failure, cardiacarrhythmias, seizures, tetany and sudden death.The emergency treatment involves control of thehyperkalaemia, correction of the hypocalcaemiaand hyperhydration to prevent urate nephropathy.Due to the rapid release from destroyed tumourcells, the rise in serum potassium is much more

rapid in tumour lysis syndrome than that seen inrenal failure. Continuous haemodiafiltration maybe required. These patients should be managed onan intensive care unit.

All patients at risk of tumour lysis syndromeshould have preventative measures initiated priorto chemotherapy. These include hyperhydration,the administration of allopurinol or uricozyme andalkalinization of the urine. A more recent advancein management is the drug rasburicase, which is arecombinant urate oxidase enzyme. This hasproved very effective in prophylaxis in high-riskpaediatric patients.18 It is prudent to delay anyanaesthetic interventions until these preventativemeasures have been established.

The septic child

Children with neoplasia account for 12.8% of allcases of severe sepsis in children aged 1–9 yearsand 17.4% in those aged 10–19 years. The mortalityis 16% in those with cancer as opposed to 10% inthose without. It is higher in those who haveundergone bone marrow transplantation.19 Chil-dren with leukaemia or lymphoma differ from thosewith solid tumours with regards to their predisposi-tion to sepsis. Leukaemia is a disease of the bonemarrow and involves more intensive myeloablativetherapy compared to the treatment of solidtumours. A more prolonged period of immunedysfunction, in particular neutropenia rendersthem more susceptible to opportunistic infectionsfor longer periods.

Anaesthetists are often involved in the initialmanagement and stabilisation of the patients priorto their transfer to definitive care. It is vital thatgood communication exists between the paediatricand anaesthetic teams in order that those childrenwith established or pending septic shock berecognised and managed in a multidisciplinaryfashion. An ABC approach should be adopted. Signsof sepsis include increased respiratory rate, tachy-cardia, delayed capillary refill, cool peripheries andaltered mental state. Hypotension is a late and pre-terminal sign of circulatory failure. The childshould be administered high flow oxygen andvenous or intra-osseous access established. At thispoint blood should be sent for routine haematology,biochemistry and blood cultures. An initial fluidbolus of 20mL/kg of 0.9% saline or 4.5% humanalbumin (or gelatin-based colloid) should be givenand the response noted. Subsequent fluid bolusesshould be with colloid. The oncologists shouldadvise with regard to the most appropriate broadspectrum antibiotics on an individual patient basis.

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Children often require several boluses of fluid toachieve relative stability. After 40mL/kg it isnecessary to consider inotropes and ideally tomonitor central venous pressure. Intubation shouldbe considered after three boluses of 20mL/kg offluid have been given. Positive pressure ventilationimproves oxygenation and prevents/treats pulmon-ary oedema. Paediatric intensive care servicesshould be contacted early in order that they canguide treatment and begin to organise patienttransfer.

The role of the anaesthetist

Anaesthetists form part of the multidisciplinaryteam caring for children with malignancy. They areinvolved at every stage of the child’s journeyincluding diagnosis, treatment, disease surveil-lance, pain management and at times resuscitationon the intensive care unit.

Regular and at times daily visits to the hospitalcan have profound psychological effects onboth the child and their parents. The disruptionto their normal routine must be limited as muchas possible. This includes clear guidelines withregard to starvation and morning sessions toallow return to school or nursery in the afternoon.Full explanations should be given to parents andtheir involvement at induction of anaesthesiaencouraged.

Anaesthesia is often conducted in isolated sitessuch as radiotherapy suites, day-case oncologyunits and radiology/imaging departments. Thepersonnel involved in anaesthetising and recoveringthese patients should have the appropriate paedia-tric training. Wherever possible the environmentshould be as ‘child-friendly’ as possible. At alltimes there should be full paediatric resuscitationfacilities available.

Figure 2 There is a thermoplastic mould is in positionover this child’s head ready for radiotherapy treatment.The peri-nasal catheter for carbon dioxide sampling canbe seen taped to the mould.

Anaesthesia for radiotherapy

Radiotherapy in paediatric patients is indicated forthree main groups of cancers: brain tumours,commonly gliomas and medulloblastomas; tumoursoutside the central nervous system, e.g. neuro-blastoma, lymphoma, rhabdomyosarcoma; leukae-mia, e.g. cranial irradiation in ALL.

The goals of radiotherapy are to deliver a highdose of irradiation to the treatment area whilstsparing healthy tissue. The precise control ofpatient movement is therefore vital and generalanaesthesia is indicated in younger children. Chil-dren over 5 years will often tolerate radiotherapywithout anaesthesia with suitable preparation,

including play therapy. The ideal anaesthetic forradiotherapy should be rapid in onset, of briefduration with prompt recovery, and assure immo-bility and a patent airway in a variety of positions.There have been no randomised studies in paedia-tric patients to demonstrate the superiority of anyone anaesthetic technique.

In our institution we employ a technique of totalintravenous anaesthesia by means of a propofolinfusion.20,21 The appeal of propofol is that it hasrapid onset and awakening; it has a low incidenceof side effects and in addition has antiemeticproperties. The technique avoids repeated instru-mentation of the airway and daily exposure tovolatile agents. Opioid analgesia is not required asradiotherapy is not painful and opioids are asso-ciated with hypoventilation and apnoea. To facil-itate vascular access nearly all children scheduledfor a prolonged course of radiotherapy should havea long-term central venous device inserted, e.g.PortacathTM or HickmanTM line. A course of radio-therapy maybe from 10 days (e.g. abdominalneuroblastoma) to 7 weeks, (in some brain tu-mours). The total dose is fractionated to reduce theincidence of side effects.

If the area to be irradiated involves the head orcervical spine a mould needs to be made of thepatients head. This mould will subsequently ensurethe accuracy of the treatments. The mould is madeusing a sheet of thermoplastic. Whilst warm this isdraped over the patient, as it cools it hardensaround the contours of the child head (see Fig. 2).There are pre-made holes in the sheet for thenostrils and mouth. As the sheet hardens it isimportant that the child can maintain their airwaywithout obstruction. If the mould is made correctlyit is very rare for the child to need any artificial

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P. Evans, D. Chisholm56

airway device, however we do insert a biteblock to act as spacer between the teeth whenmaking the mould. If the child subsequentlyneeds an oropharyngeal airway or a LMA there willthen be enough space between the teeth forinsertion.

The radiotherapy suites are often in the mostgeographically isolated areas of a hospital. Pipelinegases and vacuum are not always available. It isimportant to ensure there is full resuscitationequipment and backup sources of oxygen andsuction available prior to inducing anaesthesia.For simplicity we use a self-inflating resuscitationbag and mask system with a portable monitorrather than an anaesthetic machine.

A parent accompanies the child to the radio-therapy suite. With appropriate communication thechild’s waiting time in this predominantly adultoutpatient setting can be kept to a minimum.Induction takes place within the treatment roomwith the child either on the trolley or on theparent’s knee. The aim is to maintain spontaneousrespiration at all times. A bolus of 3–5mg/kg ofpropofol is given via a pump over 1–2min (morerapid injection is associated with apnoea). Acontinuous infusion of propofol is commencedtypically at a rate of 10mg/kg/h and is adjustedto response. The patient is transferred onto thetreatment table. They are carefully positioned andthe mould applied (see Fig. 3a). The child iscontinuously observed to confirm an unobstructedrespiratory pattern. A capnography catheter ispositioned perinasally on the mould to produce areliable waveform on the monitor and supplemen-tal oxygen can be delivered by taping a facemask tothe mould.

The requirement for children to be positionedprone for radiotherapy has almost disappeared dueto improvements in conformation radiotherapytechniques. However the technique describedworks equally well for prone patients. Childrenhaving abdominal or peripheral radiotherapy do not

Figure 3 (a) Patient in position for radiotherapy treatmentcontrol room views of the child, anaesthetic monitor and inf

require a mould for treatment. Their head issupported to one side with a foam wedge, againan artificial airway is very seldom required.

The monitor is positioned so that it can beviewed via a closed-circuit TV camera, whilstanother camera observes the child. During thetreatment the anaesthetic team observe the childand monitor via TV screens in the control room(see Fig. 3b). Although the value for end-tidalcarbon dioxide is not accurate using this method, itdoes give a reliable trend of adequate ventilationand respiratory pattern. At the end of theprocedure the patient is transferred for recoveryin a designated area within the radiotherapysuite. Emergency drugs, a self-inflating resuscita-tion bag and advanced airway equipment togetherwith portable suction should be available at alltimes.

This technique is associated with a shortawakening time and rapid psycho-motor recovery.Patients can be rapidly transferred back toward and are usually eating within 20min ofthe end of the procedure. Studies have shownthat using this technique mean awakening timeis 4min and discharge home can be as soon as30min.

Other methods for anaesthesia for radiotherapyinclude the use of ketamine or inhalational agents.Ketamine can be administered intravenously or lesscommonly now intramuscularly. It is howeverassociated with excess salivation and increases inintracranial pressure. Methods using inhalationalagents usually require repeated instrumentation ofthe airway with a LMA or endotracheal tube. Thereare also issues with regards to adequate scavengingof anaesthetic gases.

Anaesthesia for short painful procedures

Short painful procedures include lumbar puncture,bone marrow aspirate and trephine biopsy. The

, in this case for an optic chiasm glioma. (b) Inside theusion pump are displayed on closed-circuit TV screens.

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number of these procedures being performed hasincreased. This reflects the increasing use ofintrathecal methotrexate rather than radiotherapyin central nervous system prophylaxis and the movetowards ‘risk-directed’ treatment strategies. Thisapproach requires regular bone marrow aspirationsduring treatment in order to assess the patient’sresponse to current therapy and plan subsequentchemotherapy regimes.

The aims of anaesthesia for these interventionsare to provide analgesia and amnesia whilstensuring minimal side effects and disruption tothe child’s routine.22 This is achieved using either atotal intravenous anaesthesia technique or acombination of intravenous and inhalationalagents. There is evidence that the recovery andside effect profile is more favourable with anintravenous technique. In our institution we use acombination of propofol and remifentanil to facil-itate anaesthesia for these procedures.23

The child should be fasted as per local protocol.Platelet count and clotting should be checked priorto the procedure and any abnormalities corrected.Each haematology unit will have there own policybut typically the platelet count should be above50� 109/L for lumbar puncture and 20� 109/L forbone marrow aspiration.

The majority of these children will have long-term intravenous access. Children with Porta-cathsTM will require them to be accessed priorto induction. Using a clean technique, anaesthesiais induced with propofol 3mg/kg then remifentanil1mcg/kg via the indwelling central access. Oxygenis administered via an anaesthetic breathingcircuit and ventilation is assisted as necessary.The patient is then positioned in the lateralposition. Supplemental injections of remifentanil0.5mcg/kg or propofol 0.5–1mg/kg are given ifthe patient moves or shows signs of response tostimuli. This technique ensures a rapid induction,minimal movement during the procedure andeliminates the need for scavenging. Propofolonly intravenous techniques have also been de-scribed.24 The advantage of adding remifentanilis that is has a propofol-sparing effect anddiminishes movement to stimuli. However, it doesincrease the incidence of apnoeas and the needfor assisted ventilation for a short period afterinduction.

Inhalational anaesthetic techniques are asso-ciated with a longer induction and more delayedrecovery and a higher incidence of nausea andvomiting. Again scavenging of anaesthetic gasesusing open paediatric circuits is an issue withimplications for staff exposure during high volume,rapid turnover lists.

Anaesthesia for long-term central venousaccess

Children should have central access secured asearly as possible in their course of treatment. Itfacilitates not only the administration of che-motherapy agents but also reduces the anxietyassociated with repeated anaesthetics. However, itis precisely because these lines are inserted early inthe course of treatment that the anaesthetist mustbe alert to potential hazards. These include thepresence of a mediastinal mass; the risk of tumourlysis syndrome, DIC associated with asparaginaseand the risk of infection if the white cell count islow (this usually reaches a nadir at 5–10 days postdose with recovery by day 21).

The anaesthetic technique used should prefer-ably include endotracheal intubation and positivepressure ventilation. This avoids the distortion tothe anatomy of the great vessels in the neck causedby an LMA. There is also a serious risk of airembolism if these patients are spontaneouslybreathing.

Conclusion

Children with malignancy represent a uniquepatient group. Although they often require anaes-thesia for relatively minor procedures, the poten-tial for serious deterioration under anaesthesia isvery real. Anaesthetists form part of a multi-disciplinary team involved in the care of thesechildren who often undergo long and protractedtreatment regimes. The anaesthetic techniquesemployed must be safe but at the same time aimto have minimal impact on the child’s normal dailyroutine.

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