General Principles for Intensive Care Management of Pediatric Patients With Cancer

Introduction/Overview

The most common cancers in the pediatric population are acute leukemia, central nervous system (CNS) tumors, nephroblastoma, neuroblastoma, lymphoma, and sarcoma (see Chapter 45 ). The most common surgeries performed in pediatric patients with cancer are for central access for treatment (port or central line placement) and tumor resections. Caring for these children in the postoperative period requires knowledge of their cancer and previous therapies. Commonly, patients are often immunocompromised and may have single or multiple organ dysfunction or damage resulting from the disease or treatment-related effects. This may include cardiac dysfunction, radiation-induced tissue damage, acute or acute-on-chronic kidney injury, electrolyte imbalances, adrenal insufficiency, or malnutrition.

A systematic preoperative evaluation of the patient is vital for successful postoperative management. Discussion between the intensive care unit and anesthesia clinicians before surgery may help mitigate problems in the postoperative period. Postoperative planning includes the timing of extubation, the optimal location for immediate recovery from anesthesia, and the anticipation of pain control issues. These decisions should be communicated ahead of time with staff in the postanesthesia care unit (PACU), intensive care unit, and pediatric ward. In addition, a complete and thorough handoff should be provided between teams. An example of a handoff form is shown in Table 48.1 .

Table 48.1

PACU Handoff Checklist

Patient Identification (Name band check)
Duration/length of procedure	Hours, minutes
Allergies	NKDA
Surgical procedure and reason for surgery
Type of anesthesia (GA, TIVA, regional)
Surgical or anesthetic complications
Past medical history
Preoperative vital signs	T, HR, BP, RR, O ₂ sat
Position of the patient (if other than supine)
Intubation conditions (grade of view, airway, quality of bag-mask ventilation)
Circulation/need for vasoactive medications	Stable/unstable
Lines/catheters/drains
Fluid management (fluids in, estimated blood loss, urine output)	IVF/UOP
Analgesia plan during case, postoperative orders
Antiemetics administered
Medications due for administration during PACU (antibiotics, etc.)
Other intraoperative medications (steroids, antihypertensives)
Family updated	Yes/No

BP, Blood pressure; GA, general anesthesia; HR, heart rate; IVF, intravenous fluid; NKDA, no known drug allergies; O2 sat, oxygen saturation; PACU, postanesthesia care unit; RR, respiratory rate; T, temperature; TIVA, total intravenous anesthesia; UOP, urine output.

Airway

The timing of extubation should be planned before the surgery begins. Extubation may occur immediately after surgery or be delayed for days in the intensive care unit due to airway risk (e.g., postoperative swelling), pulmonary edema, or hemodynamic instability. Patients who have undergone neurosurgery, oral-maxillary-facial surgery, or cardiac or thoracic surgery may benefit from postoperative mechanical ventilation for monitoring and management of tissue edema compromising the airway, or for hemodynamic and ventilatory optimization. Other considerations unique to pediatric patients with cancer include painful mucositis, restricted mouth opening (trismus), or a history of radiation to the neck requiring a well-planned process, given the potential for critical airway complications. Mucositis causes moderate to severe pain, friable oral tissue, edema, and bleeding. Restricted mouth opening may be seen in several pediatric conditions, including mandibular/temporomandibular joint radiation, Pierre Robin syndrome, Carpenter syndrome, Goldenhar syndrome, Crouzon disease, Freeman-Sheldon syndrome, Treacher-Collins syndrome, Klippel-Feil syndrome, ankylosing spondylitis, and rheumatoid arthritis (see Chapter 46 ). Macroglossia is associated with specific syndromes, including trisomy 21, Hurler syndrome, and Beckwith-Wiedemann syndrome, and can challenge reintubation or maintaining an oral airway. Radiation to the neck can cause tracheal stenosis, affecting the airway, and may require fiberoptic intubation and a smaller than average endotracheal tube size, especially if the need for reintubation arises. Neurosurgical procedures, especially those involving the posterior or infratentorial fossa, may affect cranial nerve function and lead to a neurologic pathology affecting breathing and swallowing.

Residual anesthesia effects may lead to upper airway obstruction due to the loss of pharyngeal airway tone. The tongue falls back against the posterior pharynx and obstructs the gas flow. Vocal cord swelling or subglottic edema that may occur with intubation can also cause upper airway obstruction and stridor. Cool mist, sedation, pain medications, racemic epinephrine nebulizer treatments, and intravenous dexamethasone are treatment options for airway edema causing stridor. In patients who have undergone thyroid, parathyroid, or aortic surgery, damage to the recurrent laryngeal nerve is possible. This may cause vocal cord paresis or paralysis, resulting in stridor or voice hoarseness. Patients undergoing neurosurgery of the posterior or infratentorial fossa may also have paresis or paralysis of the vocal cords, leading to vocal cord dysfunction and difficulty in breathing. In addition, cranial nerve deficits may also impair swallowing and weaken cough, leading to pooling and aspiration of secretions.

Breathing

Mechanical Ventilation

Residual anesthesia is the most common cause of respiratory failure after surgery. Volatile agents used for anesthesia, benzodiazepines used to decrease anxiety, or opioids used to manage surgical pain may cause prolonged sedation and respiratory depression. Lung protective ventilation strategies should be used in patients needing continued mechanical ventilation postoperatively. Inspiratory volumes up to 8–10 mL/kg, positive end-expiratory pressure (PEEP) of 5–8 cmH ₂ O, and an age-appropriate respiratory rate should be used in patients with compliant lungs. In diseased lungs, acute lung injury, or respiratory distress syndrome, the mechanical ventilator volumes should be set to 4–8 mL/kg while maintaining plateau pressures of less than 30 cmH ₂ O and allowing for permissive hypercapnia.

Pediatric oncology patients may experience lung injury before surgery due to direct pulmonary toxicity from chemotherapy or radiation. Bleomycin, busulfan, cyclophosphamide, and nitrosoureas are chemotherapeutic agents known to cause rales, fever, and dyspnea at therapeutic levels. Methotrexate, cytarabine, ifosfamide, cyclophosphamide, interleukin (IL)-2, all-trans retinoic acid, and bleomycin may cause endothelial injury and vascular leakage, which can lead to noncardiac pulmonary edema. Dose-dependent radiation damage can present with cough, dyspnea, and pink sputum up to 3 months after treatment. One to two years after treatment, radiation damage can cause fibrosis, increased oxygen requirement, and decreased pulmonary function. Reviewing previous cancer therapies, current symptoms, chest imaging, and previous pulmonary function testing can provide helpful knowledge regarding lung damage.

Noninvasive Ventilation

Discontinuing mechanical ventilation immediately postoperatively decreases the risk of iatrogenic lung injury. The use of noninvasive positive pressure ventilation (NIV), continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) provides respiratory support when patients are recovering from anesthesia. These strategies provide respiratory support by preventing alveolar collapse in patients who are spontaneously breathing. Contraindications for NIV use include the following:

Patient’s inability to protect their airway
Glasgow coma scale <8
High risk of cardiac arrest
Hemodynamic instability
Rapidly progressive neuromuscular weakness
Unable to correctly fit the face mask (facial tumors, facial surgery)
Untreated pneumothorax
Vomiting or risk of aspiration
Skin breakdown that may be exacerbated by tight-fitting mask

High-Flow Nasal Cannula Therapy

High-flow nasal cannula (HFNC) therapy delivers heated and humidified oxygen via nasal prongs at recommended flow rates of 2–8 L/min for neonates and 4–70 L/min for children. An air-oxygen blender allows the percentage of oxygen delivered to the patient to be adjusted. HFNC is well tolerated in pediatric patients, from neonates through adolescence, and works to improve alveolar oxygen delivery through the generation of PEEP and dead space carbon dioxide washout. The heated and humidified flow prevents airway dryness, which preserves mucociliary function and enhances secretion clearance. Ideally, HFNC decreases the work of breathing and the need to escalate respiratory support to either CPAP or BiPAP and is often better tolerated than positive pressure ventilation with CPAP or BiPAP. HFNC may provide some positive pressure at sufficiently high flows, but this is limited due to multiple variables affecting the transmission of flow to the patient. The ability of HFNC to prevent the need for mechanical ventilation or to prevent mortality has been inconsistently supported in previous studies.

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