Anaesthetic perioperative management of patients with pancreatic cancer

Table 1 A schematic representation of the integrated management of perioperative patients undergoing surgery for pancreatic cancer

Preoperative	Intraoperative	Postoperative
Informed patient consent	Combined general and epidural analgesia	Early nasogastric tube, catheter and drain removal
Preoperative risk assessment	Prevention of surgical site infection: Antimicrobial prophylaxis Avoid hypothermia Glucose control	Early oral nutrition/glycaemic control/goal-directed fluid therapy
		Pain relief/non-opioid oral analgesia
Evaluation and optimisation of preoperative physical conditions and medications	Blood transfusion management	Intensive postoperative ambulation and prevention of venous thromboembolism
Nutritional status	Intraoperative fluid management	Intensive respiratory rehabilitation
Risk stratification, rationale for thromboprophylaxis, and recommendations	Optimisation of intraoperative ventilation Intraoperative thromboprophylaxis	Intensive postoperative management

Modified from Grade et al[10].

Table 2 Perioperative clinical predictors of postoperative pulmonary complication in pancreatic oncological surgery

Patient-related factors	Surgery-related factors	Preoperative testing-related factors
Congestive heart failure	Abdominal surgery	Serum albumin concentration < 2.5 g/dL
ASA score > 2	Surgery duration > 3 h	Anaemia (Hb < 10 g/dL)
Age > 65 yr	General anaesthesia	Low SpO2
Chronic obstructive pulmonary disease	Transfusions	Chest X ray
Functional dependence	Prolonged hospitalisation
Weight loss
Impaired sensorium
Cigarette smoking
Respiratory infections within the past month

Modified from Canet et al[36]. ASA: American Society of Anesthesiologists.

Table 3 Guidelines on the prophylaxis of venous thromboembolism and antiplatelet and anticoagulant management adjusted according to recent guidelines

In patients receiving bridging anticoagulation with a therapeutic-dose IV of unfractionated heparin, treatment is recommended to be stopped no later than at 4 to 6 h prior to surgery

In patients receiving bridging anticoagulation with a therapeutic-dose of LMWH, the last preoperative dose of LMWH is recommended to be administered at approximately 24 h prior to surgery instead of at 12 h prior to surgery

In patients receiving bridging anticoagulation with a therapeutic-dose of LMWH and are undergoing high-bleeding-risk surgery, resumption of the therapeutic dose of LMWH is recommended at 48 to 72 h after surgery instead of within 24 h following surgery

In moderate-to-high-risk patients receiving acetylsalicylic acid who require non-cardiac surgery, treatment with acetylsalicylic acid is recommended to be continued around the time of surgery instead of discontinued at 7 to 10 d prior to surgery

In patients with a coronary stent who require surgery, deferment of surgery is recommended at 6 wk or 6 mo after the placement of a bare-metal or drug- eluting stent, respectively, instead of initiating surgery during these time periods

In patients requiring surgery within 6 wk or 6 mo of the placement of a bare-metal or drug-eluting stent, respectively, continuing perioperative antiplatelet therapy is recommended instead of stopping therapy at 7 to 10 d prior to surgery

Modified from Douketis et al[62]. LMWHs: Low-molecular-weight heparins.