July FY22

[kristenhorsman]

The journal club for the month of July is presented by Cathy Lawry. She chose an article that she thought would interesting regarding the use of TIVA and regional anesthesia for oncology patients.



The two questions for discussion are:



1. Due to the data suggesting that volatile agents and opioids may cause immunosuppression, are you currently implementing TIVA with propofol/regional and ERAS techniques in the oncology population?

2. Do you currently use COX-2 inhibitors on a regular basis when taking care of oncology patients? Why or why not?

[LarSharVeA Bailey]

This is a great article Cathy! I have not selectively used TIVA in oncology patients with these research findings as a basis for my practice. Adoption of propofol is relatively facile; thus going forward, I will prioritize doing so. I have, however, routinely ordered celebrex preoperatively for these patients because of the ERAS protocol. I am pleased to learn of it's anti-tumorigenic effects.

[Katya]

1. I don't use strait TIVA for oncology patients but add Propofol for most of my patients for other reasons ( antiemetic effect, nice emergence form anesthesia, reduced amount of other anesthetics, and fast wake up if I use low dose infusion). And now I learned another reason to use more Propofol.
2. I use COX-2 inhibitors for ERAS cases but not oncology cases (like breast CA or thyroid CA), many surgeons don't like to give it preop. But I like to add ketorolac as NSAD for many appropriate cases.

[aileenm4]

1. I do a majority of the peds oncology cases with TIVA propofol
2. WE use Cox2inhibitors not often in peds unless it is in a best practice protocol

[Soo-Ok Kim]

1. I use TIVA in oncology patients with propofol for especially regular BMP/LP with chemo.

2. 
Depending on the stage of oncology treatment process... I don't regularly use COX2 inhibitor for thrombocytopenia with chemo.

[Anne McNulty CRNA]

I have been using TIVA on oncology pts since the ERAS protocols were started. If regional is possible, I will always give a little push for the benefits. Iv Acetaminophen is very effective. I use cox 2 inhibitors as well as Ketorolac as long as there are no contraindication. I have not given Morphine iv in at least 15 years. I avoid dexamethasone unless it is necessary. Avoiding transfusion and careful fluid replacement is always helpful to avoid inflammatory responses in oncology patients.

[Monica Douglas]

1. Due to the data suggesting that volatile agents and opioids may cause immunosuppression, are you currently implementing TIVA with propofol/regional and ERAS techniques in the oncology population?

Prior to reading this article, I routinely use TIVA with most patients, secondary to its antiemetic effects and ease of emergence. Now that I learned that volatile agents may cause immunosuppression, I will be more mindful of using TIVA with my oncology patients.

2. Do you currently use COX-2 inhibitors on a regular basis when taking care of oncology patients? Why or why not?

Working in JHOC, I do not use COX-2 Inhibitors on a regular basis. However, I do use/advocate for ketorolac (NSAID) as part of a multimodal approach to pain management.

[Dahlia Rouchon, CRNA]

Thank you for this interesting article. In regards to your inquiry:
1. I routinely use TIVA when indicated for cancer surgery (typically for smaller outpatient cases such as breast, bladder, ENT etc. ) where large fluid shifts are not anticipated. Large organ cancer surgeries I find is harder to employ TIVA only as for 3rd spacing fluid loss/resuscitation/electrolyte shifts and the length of these surgeries prevent its use. Often when TIVA is in progress after 12hrs when taking over these cases, it must be turned off, IA on and a reassessment of fluid management/blood administration must be employed guided by lab results. It is helpful as positive changes in vasopressor use may be adjusted as a result.
2. I do not routinely use COX-2 inhibitors without consultation with surgery. I find for breast procedures the surgical team is supportive of its use but procedures where potential for large blood loss is present it is discouraged.

[kels]

At the moment I do not run TIVA on all oncology patients but after this article maybe I should

I tend not to use COX-2 inhibitors unless indicated by and ERAS protocol

[Jessica Hadley]

Thank you for this article, Cathy.

1. I usually use a mix of TIVA or Propofol with < .5 MAC of VA with a majority of the cancer cases. After reading this article, I am more aware of the benefits of a straight TIVA approach. I do agree with Dhalia that Propofol is harder to use in larger cancer cases that have resulting fluid shifts etc.

2. I do not use COX-2 inhibitors currently.

[emedina1]

I mostly work in out patient surgery. I am very fond of TIVA on short cases. My personal observation,
cancer parients usually respond with drastic low BP with the start of volatile anesthetic. I have a very
good control of the pt's dept of anesthesia.


I usually include the surgeon in my decision to give cox-2 inhibitors.

[Ben Waldbaum]

1. Evidence is mixed and until better data and consensus emerge, no change in practice is necessary as the article states.

2. I only use COX2 inhibitors in collaboration with surgical team

[Amy Schutter]

1. I currently use TIVA +/- 0.5 MAC of VA with surgical CA patients. The article is very interesting and I will consider those benefits of straight TIVA going forward.
2 I use COX2 inhibitors only after discussion with surgeon.

[Amy Swank]

1. Since I have been working with the ambulatory populations at JHOC and GSS, I am very fond of the TIVA techniques utilized here. Now, I will definitely use purposefully with the oncology cases as the information presented in the journal article is quite compelling. I try to avoid Inhalational agents - but thought it interesting that Desflurance promotes NK cell activity, while Sevo and Iso do not. More reasons to use more opioid sparing techniques too.

2. I haven't been using Cox2 inhibitors, but rather preop PO acetaminophen. It might be worth collaborating with the surgeon and giving COX2 inhibitors instead.

Thanks for info!

[clawry]

1. Due to the data suggesting that volatile agents and opioids may cause immunosuppression, are you currently implementing TIVA with propofol/regional and ERAS techniques in the oncology population?


I try to implement TIVA with cancer cases when appropriate. I agree that it is more difficult in larger/all day cancer cases. I try to use opioid sparing techniques with regional as much as possible. 


2. Do you currently use COX-2 inhibitors on a regular basis when taking care of oncology patients? Why or why not?

I do not use COX-2 inhibitors on a regular basis, however I am willing to use them and see the benefit in using them as long as the surgeon approves of their usage.