5 / 21
Page 28
Volume 2
Journal of Molecular Cancer
Cancer & Primary Healthcare 2019
May 20-21, 2019
Cancer Research & Oncology
Primary Healthcare and Medicare Summit
May 20-21, 2019 | Rome, Italy
25
th
Global Meet on
World Congress on
&
Anesthetic management of a patient with cancer and hyperhomocysteinemia
Cindy Yeoh
Memorial Sloan Kettering Cancer Center, USA
Case:
A 57-year-old female with a history of uterine and breast cancer s/p chemoradiation presented for
cervical LEEP/cone biopsy/D&C. Her medical history was complicated by elevated LFTs with recent
hyperhomocysteinemia (> 50micromol/l, normal 4-15). She was seen by a hematologist prior to surgery, and
it was concluded that elevated homocysteine levels were due to cancer therapy and alcohol consumption. The
procedure was performed under monitored sedation, with 2mg of Midazolam, 50mcg of Fentanyl, and a bolus
of 70mg of Propofol followed by a steady infusion of 150mcg/kg/min.
Discussion:
Causes of hyperhomocysteinemia include genetic predisposition, acquired deficiencies (folate, B6,
B12), malignancies, and renal disease. Elevated homocysteine levels result in thromboembolic complications
by causing endothelial dysfunction, increasing procoagulant activity, and decreasing antithrombotic
effect. Challenges of patients with hyperhomocysteinemia undergoing anesthesia are related mainly to the
procoagulant state and efforts should be focused on thromboprophylaxis and maintenance of hemodynamics
and euvolemia. Nitrous oxide should be avoided as it inhibits methionine synthase and can further increase
homocysteine levels. Patients with co-morbidities that include coronary artery disease, peripheral vascular
disease, and cerebrovascular disease are at increased risk for peri-operative thrombotic events. This risk is
amplified for high-risk procedures under general anesthesia.
Conclusion:
In this case, the patient presented for a low-risk procedure. She did not have a history of coronary
or cerebrovascular disease, but had risk factors (surgery, age>50yrs, malignancy, cancer therapy) in addition
to a hypercoagulable state (due to elevated homocysteine levels) that posed increased peri-operative risk
for thrombotic events such as deep venous thrombosis and pulmonary embolus. The decision was made to
proceed with monitored sedation over general anesthesia so as to avoid fluctuations in hemodynamics and
decrease the risk of venous stasis. The procedure took approximately 45 minutes and the patient recovered
uneventfully and was discharged home the same day.
Biography
Cindy Yeoh is an associate attending in the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering
Cancer Center in New York. She is a member of the department’s Quality Assurance Committee and her research interests include
patient safety, outcomes and performance, and technology in the field of anesthesiology. Her recent publications have focused on
real-time locating systems and its effects on the efficiency of anesthesiologists in the perioperative setting.
yeohc@mskcc.orgJ Mol Cancer, Volume 2