Evaluación y Manejo Preoperatorio de Pacientes Con Cáncer - UpToDate

14/3/23, 23:02 Evaluación y manejo preoperatorio de pacientes con cáncer - UpToDate
Reimpresión oficial de UpToDate ®

www.uptodate.com © 2023 UpToDate, Inc. y/o sus afiliados. Reservados todos los derechos.
Evaluación preoperatoria y manejo de pacientes con

cáncer
Autores: Ellen F. Manzullo, MD, FACP, Sunil K. Sahai, MD, FAAP, FACP, Harrison G Weed, MS, MD, FACP
Redactor de sección: Reed E. Drews, MD
Redactor adjunto: Sadhna R. Vora, MD
Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .
Revisión de la literatura actual hasta: febrero de 2023. | Última actualización de este tema: 28 de marzo de
2022.
INTRODUCCIÓN
El manejo preoperatorio del paciente con cáncer puede ser complejo. Si bien los pacientes con
cáncer son similares en muchos aspectos a los que no tienen cáncer, los efectos directos e
indirectos (sistémicos) del cáncer y los efectos secundarios de la terapia del cáncer pueden
influir en la evaluación y el manejo perioperatorios. Aquí proporcionaremos una descripción
general de los problemas que son relevantes para los pacientes con cáncer actual o pasado. La
evaluación preoperatoria general y la estimación del riesgo cardíaco de la cirugía se analizan en
otra parte. (Consulte "Evaluación médica preoperatoria del paciente adulto sano" y "Evaluación
del riesgo cardíaco antes de la cirugía no cardíaca" .)
La evaluación médica preoperatoria de los pacientes con cáncer debe incluir una evaluación del
estado nutricional, el estado funcional y el control de los síntomas (particularmente con
respecto al dolor relacionado con el cáncer), además de una evaluación de los problemas
médicos generales. También se debe considerar la historia natural del cáncer y los efectos de
cualquier quimioterapia o radioterapia previa. Los resultados a corto y largo plazo de la cirugía
del cáncer en pacientes mayores pueden ser equivalentes a los de los pacientes más jóvenes.
Las consideraciones de tratamiento deben basarse en el estado funcional, no en la edad
cronológica [ 1 ]. (Consulte "Evaluación geriátrica integral para pacientes con cáncer" .)
https://www.uptodate.com/contents/preoperative-evaluation-and-management-of-patients-with-cancer/print 1/45
El momento y el propósito de la cirugía del cáncer pueden afectar la evaluación perioperatoria.

Si bien rara vez se trata de una emergencia, la cirugía del cáncer generalmente no es electiva y,
por lo tanto, la cantidad de tiempo disponible para optimizar médicamente a un paciente
puede ser limitada.
Cada vez se reconoce más que la aptitud fisiológica del paciente para la cirugía desempeña un
papel en la reducción de las complicaciones perioperatorias. Los pacientes con cáncer tienden a
estar desacondicionados debido a numerosos factores. En esta situación, en la que los
pacientes sufren numerosas agresiones a su estado funcional general, puede ser beneficioso
inscribir a los pacientes en un programa de prehabilitación tan pronto como se realice el
diagnóstico de cáncer ( figura 1 ).
Además de manejar las condiciones médicas coexistentes, el internista también puede

desempeñar un papel importante en la coordinación de los muchos niveles complejos de
atención que brindan los cirujanos, los oncólogos médicos, los oncólogos radioterápicos y
otros.
NUTRICIÓN
Si es posible, recomendamos consultar con un nutricionista para todos los pacientes con cáncer
para los que se contempla la cirugía, independientemente del tiempo de operación.
Los pacientes con cáncer pueden sufrir una desnutrición significativa por diversas razones.
Comer y beber puede verse afectado por dolor, náuseas, estomatitis o tumores que afectan la
orofaringe o el tracto gastrointestinal. Además, las aberraciones metabólicas pueden inducir
anorexia y pérdida de peso. (Consulte "Patogénesis, características clínicas y evaluación de la
caquexia por cáncer" .)
The indiscriminate use of enteral or parenteral nutrition is not indicated in well-nourished

patients or those with mild malnutrition. Although many studies have failed to demonstrate a
survival benefit from preoperative nutritional support in patients undergoing cancer surgery,
some have found fewer operative complications and a shorter length of hospital stay in
severely malnourished patients receiving nutritional support prior to major surgery for cancers
of the digestive tract and the head and neck. (See "The role of parenteral and enteral/oral
nutritional support in patients with cancer", section on 'The perioperative setting'.)
On the other hand, nutrition optimization is an important component of enhanced recovery

programs for surgical patients. (See "Overview of prehabilitation for surgical patients", section
on 'Nutritional supplementation'.)
Thus, preoperative nutritional support for cancer patients may be reasonable in the following
circumstances:
● Seven to 10 days of preoperative parenteral nutritional support for severely malnourished

cancer patients prior to major visceral surgery
● One to two weeks of enteral nutritional support via a gastrostomy or jejunostomy feeding
tube for severely malnourished patients prior to major head and neck cancer surgery
PAIN
Patients with cancer often require medication for pain control. Those who have been receiving
opioid analgesics can be expected to have some degree of tolerance and may require dose
escalation in the postoperative period to attain adequate pain control. Many patients will be
receiving long-acting forms of opioids and may require conversion to short-acting forms of
analgesia in the perioperative period. Conversion tables are available ( table 1). (See
"Assessment of cancer pain" and "Cancer pain management with opioids: Optimizing
analgesia".)
As in other surgical patients, medications used for pain control in patients with cancer can have
important side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause bleeding,
gastritis, and impaired renal function, and opioids can cause nausea, constipation, sedation,
and delirium. (See "Prevention and management of side effects in patients receiving opioids for
chronic pain".)
NSAIDs may be contraindicated in patients with thrombocytopenia from cancer or its

treatment, and in patients with impaired renal function. Selective COX-2 inhibitors (eg,
celecoxib) do not increase nongastrointestinal bleeding risk, but as with other NSAIDs, they do
increase the risk of renal failure. (See "Overview of COX-2 selective NSAIDs" and "Cancer pain
management: Use of acetaminophen and nonsteroidal anti-inflammatory drugs".)
Patients may have concerns about postoperative pain control. These should be addressed as
part of the preoperative evaluation. The subject of managing acute pain in the patient on
chronic opioid therapy is addressed elsewhere. (See "Management of acute pain in the patient
chronically using opioids for non-cancer pain".)
CARDIOVASCULAR STATUS
Cardiac assessment — The clinician must integrate information from the history, physical
examination, and electrocardiogram (ECG) in order to develop an initial estimate of
perioperative cardiac risk.
An algorithmic approach to assessment of cardiac risk prior to noncardiac surgery is provided

( algorithm 1). This subject is addressed elsewhere. (See "Evaluation of cardiac risk prior to
noncardiac surgery".)
The following sections address specific issues that arise in patients with cancer.
Pericardial disease — Patients with cancer are at risk for malignant and non-malignant
pericardial disease. Metastases to the pericardium can cause effusions, tamponade, and
constrictive pericarditis. (See "Pericardial disease associated with malignancy".)
Radiation therapy to the mediastinum can also cause constrictive pericarditis or effusions with
or without tamponade. Pericarditis can present months to years after radiation treatment [2].
(See "Constrictive pericarditis: Diagnostic evaluation" and "Cardiac tamponade".)
Echocardiography should be performed if physical examination reveals findings consistent with

tamponade or constriction (eg, hypotension, jugular venous distension, narrowed pulse
pressure, distant heart sounds, or excessive respiratory variation in blood pressure) or if
electrocardiography or imaging suggests a significant pericardial effusion.
Tamponade and constrictive pericarditis must be treated prior to surgery whenever possible.
Patients with asymptomatic malignant pericardial effusions should be carefully monitored for
the development of tamponade in the perioperative period.
Coronary, electrical, and valvular heart disease — Radiation therapy to fields that include the
heart can lead to premature coronary heart disease (CHD). Radiation to the heart may also be
associated with conduction abnormalities [3]. Therefore, younger patients who might not
otherwise be expected to be at risk for CHD, but who have a history of thoracic radiation
therapy for cancer, should be assessed for symptomatic CHD as part of the preoperative history
and review of systems, and should have a preoperative screening ECG. (See "Cardiotoxicity of
radiation therapy for breast cancer and other malignancies".)
Radiation therapy has also been associated with valvular heart disease, particularly of the mitral
and aortic valves [4-6]; therefore, careful cardiac auscultation is an important part of the
preoperative examination. (See "Cardiotoxicity of radiation therapy for Hodgkin lymphoma and
pediatric malignancies", section on 'Valvular heart disease'.)
However, antibiotic endocarditis prophylaxis is not necessarily indicated. The 2007 American
Heart Association guideline for the prevention of infective endocarditis (which was updated in
2008) narrowed the indications for bacterial endocarditis prophylaxis, compared with prior
versions, in recognition of the absence of strong supportive evidence [7,8]. Antimicrobial
prophylaxis is not indicated unless the patient has a history of endocarditis. Guidelines from the
combined American Heart Association/American College of Cardiology and the European
Society of Cardiology are largely in agreement with this approach [9,10].
Carotid artery disease — Survivors of head and neck cancers who have received radiation
therapy to the neck are at risk for radiation-induced carotid stenosis and, as such, may need
review and documentation of the most recent carotid ultrasound. [11]. (See "Management of
late complications of head and neck cancer and its treatment", section on 'Carotid artery injury'
and "Overview of approach to long-term survivors of head and neck cancer", section on
'Damage to the carotid arteries'.)
Cardiac toxicity from chemotherapy — Certain chemotherapeutic agents, particularly

trastuzumab and the anthracyclines, cause significant cardiotoxicity. Dose-dependent
cardiomyopathy and heart failure may be seen in patients who have received cumulative doses
of over 550 mg/m2 of doxorubicin or 600 mg/m2 of daunorubicin [12]. Pre-existing heart
disease, radiation therapy, and exposure to other chemotherapeutic agents (eg, taxanes,
trastuzumab) can lower the cumulative anthracycline dose threshold at which cardiomyopathy
develops. (See "Clinical manifestations, diagnosis, and treatment of anthracycline-induced
cardiotoxicity" and "Risk and prevention of anthracycline cardiotoxicity" and "Cardiotoxicity of
cancer chemotherapy agents other than anthracyclines, HER2-targeted agents, and
fluoropyrimidines" and "Cardiotoxicity of trastuzumab and other HER2-targeted agents".)
Electrocardiographic abnormalities such as sinus tachycardia, premature atrial or ventricular

contractions, nonspecific ST and T wave changes, and low-voltage QRS complexes may be early
signs of cardiotoxicity, but are insensitive indicators of myocardial dysfunction. Assessment of
left ventricular function before surgery should be considered in patients who are at risk for
cardiomyopathy since they are at increased risk for heart failure [13]. Follow-up screening
guidelines for childhood cancer survivors at risk for treatment-related heart failure are available
from the Children's Oncology group and discussed in more detail elsewhere. (See "Clinical
manifestations, diagnosis, and treatment of anthracycline-induced cardiotoxicity" and "Risk and
prevention of anthracycline cardiotoxicity".)
Perioperative management of these patients is similar to that of other patients with heart
failure who require surgery. (See "Perioperative management of heart failure in patients
undergoing noncardiac surgery".)
Several chemotherapy drugs are associated with prolongation of the QT interval, particularly
crizotinib, dasatinib, eribulin, ivosidenib, vemurafenib, and small molecule inhibitors of the
vascular endothelial growth factor, including pazopanib, sorafenib, sunitinib, lenvatinib, and
vandetanib. Patients receiving these drugs are at risk for potentially fatal arrhythmias. Risk
factors for torsades de pointes include concurrent use of other drugs that can prolong the QT
interval ( table 2) or that slow drug metabolism due to inhibition of cytochrome P450 (CYP)
enzymes, such as CYP3A4 ( table 3), and electrolyte disturbances (hypokalemia,
hypomagnesemia). Correction of electrolyte disturbances and avoidance of other QT-
prolonging drugs or strong inhibitors of CYP3A4 should be considered in patients who are
already taking a QT-prolonging drug. (See "Toxicity of molecularly targeted antiangiogenic
agents: Cardiovascular effects", section on 'Prolongation of the QTc interval and cardiac
arrhythmias'.)
In addition, checkpoint inhibitor immunotherapy may be associated with immune-mediated

myocarditis. (See "Toxicities associated with immune checkpoint inhibitors", section on
'Cardiovascular toxicity'.)
Medication management — Recommendations for management of medications for

cardiovascular risk (eg, aspirin and other antiplatelet therapy, beta-blockers) prior to noncardiac
surgery are addressed in detail elsewhere. (See "Management of cardiac risk for noncardiac
surgery".)
CARDIOPULMONARY MASS EFFECTS
Patients with tumors in or adjacent to the central airway are at risk for airway obstruction.
Stridor, or other signs or symptoms of upper airway obstruction, should be assessed
preoperatively by laryngoscopy. (See "Clinical presentation, diagnostic evaluation, and
management of malignant central airway obstruction in adults" and "Malignancy-related
superior vena cava syndrome".)
Anterior and middle mediastinal masses can compress the lower airways, heart, and major
vessels. This can lead to life-threatening airway obstruction or to cardiopulmonary arrest during
any phase of general anesthesia [14]. Therefore, the preoperative evaluation of a patient with
an anterior or middle mediastinal mass should include a detailed review for respiratory
symptoms including stridor, dyspnea, wheezing, and orthopnea, and examination for evidence
of neck or chest vein engorgement or swelling restricted to the face and neck. Imaging of the
chest with computed tomography (CT) or magnetic resonance imaging (MRI) and
echocardiography should be performed to look for central airway, cardiac, or vascular
compression. Flow volume loops should also be obtained to look for central airway
compromise. (See "Flow-volume loops" and "Approach to the adult patient with a mediastinal
mass".)
Patients with any evidence of central airway, cardiac, or major vessel compression may require
special anesthetic care and precautions, including but not limited to the following [15]:
● Fiberoptic intubation while awake

● Spontaneous ventilation throughout surgery
● Quick repositioning of the patient to the lateral, prone, or sitting position as needed
● Rigid bronchoscopy in the event of a collapsed airway
● Femoral-femoral cardiopulmonary bypass in the event of cardiovascular collapse
If surgery is being performed for the purpose of pathologic diagnosis of a mediastinal tumor
that is causing compression, serious consideration should be given to alternate diagnostic
strategies that would not require general anesthesia, such as lymph node biopsy or pleural or
sputum cytology. However, in patients with superior vena cava syndrome, invasive procedures
such as bronchoscopy and thoracoscopy can be safely carried out under general anesthesia
with minimal risk of complications. (See "Malignancy-related superior vena cava syndrome",
section on 'Histologic diagnosis' and "Malignancy-related superior vena cava syndrome",
section on 'Urgency of diagnosis and treatment'.)
PULMONARY ISSUES
Treatment-related pulmonary toxicity — Both chemotherapy and radiation therapy can

produce pulmonary toxicity, which may be intensified when they are administered
concomitantly. (See "Radiation-induced lung injury" and "Pulmonary toxicity associated with
systemic antineoplastic therapy: Clinical presentation, diagnosis, and treatment" and
"Pulmonary toxicity associated with antineoplastic therapy: Cytotoxic agents" and "Pulmonary
toxicity associated with antineoplastic therapy: Molecularly targeted agents".)
Bleomycin is associated with significant pulmonary toxicity in up to 10 percent of patients, and

treatment with supplemental inhaled oxygen (as might occur during general anesthesia) may
induce pulmonary toxicity several years after bleomycin treatment. For bleomycin-exposed
patients who undergo subsequent surgery, supplemental oxygen during surgery should be
carefully titrated and intravenous fluids should be administered sparingly to avoid volume
overload and perioperative pulmonary edema. (See "Bleomycin-induced lung injury", section on
'Supplemental oxygen and future perioperative management'.)
In addition, patients undergoing checkpoint inhibitor immunotherapy may have an immune-

mediated pneumonitis. (See "Toxicities associated with immune checkpoint inhibitors", section
on 'Pneumonitis'.)
As with other preoperative patients who may have pulmonary deficits, patients exposed to
chest radiation therapy or chemotherapy should undergo a thorough history, review of
systems, physical examination, and a preoperative chest radiograph. (See "Radiation-induced
lung injury", section on 'Diagnostic evaluation' and "Evaluation of perioperative pulmonary
risk".)
Pulmonary function testing and measurement of oxygen saturation may be appropriate for
selected patients with unexplained symptoms or abnormal examination findings. Patients at
risk of postoperative pulmonary complications can benefit from special perioperative care [16].
(See "Strategies to reduce postoperative pulmonary complications in adults".)
Pleural effusions — Patients who have a pleural effusion that is large enough to be
symptomatic may benefit from therapeutic thoracentesis prior to surgery. (See "Management
of malignant pleural effusions".)
ENDOCRINE AND ELECTROLYTE STATUS
Glucocorticoids — Many chemotherapeutic regimens include glucocorticoids, either as a

therapeutic agent or as a component of premedication to prevent chemotherapy-induced
nausea and vomiting or an infusion reaction. Glucocorticoids may unmask occult diabetes or
exacerbate previously controlled blood sugar levels. (See "Prevention of chemotherapy-induced
nausea and vomiting in adults" and "Infusion reactions to systemic chemotherapy" and
"Infusion-related reactions to therapeutic monoclonal antibodies used for cancer therapy".)
Standard recommendations for perioperative management of diabetes are available elsewhere.

(See "Perioperative management of blood glucose in adults with diabetes mellitus".)
Patients who are taking 5 mg/day of prednisone or its equivalent for more than three weeks
may have suppression of the hypothalamic-pituitary-adrenal axis (HPA) and may be at risk for
insufficient adrenal response to the stress of surgery. (See 'Adrenal insufficiency' below.)
Hyponatremia — Preoperative hyponatremia can occur in cancer patients, and may be

attributed to paraneoplastic effects of the tumor or be caused by treatments. (See
"Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone
secretion (SIADH)".)
Preoperative hyponatremia may be associated with increased risk for postoperative

complications. In a cohort study of 964,263 adults undergoing major surgery at one of 200
hospitals over a five-year period, a preoperative serum sodium concentration below 135
mmol/L was associated with significantly higher postoperative 30-day mortality (adjusted odds
ratio [aOR] 1.44), and significantly higher rates of major adverse cardiac events (aOR 1.21),
surgical site infection (aOR 1.24), and pneumonia (aOR 1.17), as well as a longer postoperative
hospitalization (by a median of one day) [17]. Because the association was actually stronger for
lower-risk surgeries and for younger patients, and was independent of the time prior to surgery
that the serum sodium was measured, hyponatremia is likely not the direct cause of
postoperative complications, but instead a marker for impaired fluid and electrolyte
homeostasis associated with chronic conditions, such as chronic heart failure.
Therefore, the best approach to the patient with preoperative hyponatremia may be to identify
the underlying impairment(s), avoid exacerbating the hyponatremia with hypotonic intravenous
solutions, and to closely monitor and carefully manage the patient in the postoperative period
[18]. (See "Overview of the treatment of hyponatremia in adults" and "Manifestations of
hyponatremia and hypernatremia in adults" and "Pathophysiology and etiology of the
syndrome of inappropriate antidiuretic hormone secretion (SIADH)".)
Hypercalcemia — Hypercalcemia is a common complication of cancer, occurring in up to 15

percent of patients [19]. Therefore, a preoperative screening serum calcium measurement is
often appropriate. If hypercalcemia is identified, then the patient's hydration should be
optimized and calcium levels normalized prior to surgery, if feasible. (See "Hypercalcemia of
malignancy: Mechanisms" and "Treatment of hypercalcemia".)
Adrenal insufficiency — Adrenal insufficiency can occur in cancer patients as a result of

adrenal suppression from chronic glucocorticoid treatment, or less commonly, from metastatic
disease to both adrenal glands. Adrenal insufficiency is also described as a rare complication of
immunotherapy with immune checkpoint inhibitors. (See "Toxicities associated with immune
checkpoint inhibitors", section on 'Endocrinopathies'.)
The presence or absence of adrenal suppression, and therefore the need for perioperative
"stress-dose" glucocorticoid coverage, can usually be predicted from the dose and duration of
the patient's glucocorticoid therapy (see "Pharmacologic use of glucocorticoids", section on
'HPA axis suppression' and "The management of the surgical patient taking glucocorticoids"):
● HPA axis suppression should be assumed to be present in patients taking prednisone at a

dose greater than 20 mg/day for three weeks or more, and in patients with a Cushingoid
appearance.
● In general, patients who have taken any dose of glucocorticoids for fewer than three
weeks or who have taken chronic alternate day therapy are unlikely to have a suppressed
HPA axis and should continue on their usual dose of glucocorticoids perioperatively.
● Patients on intermediate doses of glucocorticoids should undergo testing, although many

clinicians prefer empiric treatment with "stress-dose" glucocorticoids.
Adrenal insufficiency should be considered in postoperative patients with hypotension that is

unresponsive to intravenous fluid boluses. (See "The management of the surgical patient taking
glucocorticoids" and "Treatment of adrenal insufficiency in adults".)
Hypothyroidism — Radiation therapy to the neck can cause hypothyroidism (see "Disorders
that cause hypothyroidism", section on 'External neck irradiation' and "Management of late
complications of head and neck cancer and its treatment", section on 'Thyroid disease'):
● In one study, 41 percent of patients with Hodgkin lymphoma who received 15 to 40 Gy to

the cervical lymph nodes had hypothyroidism 20 years after treatment [20].
● In another study, almost 60 percent of patients with Hodgkin lymphoma who had received
mantle field irradiation had an elevated level of thyroid stimulating hormone (TSH) 10 to
18 years after treatment [21].
● A systemic review of radiation-induced hypothyroidism in head and neck cancer patients

suggests that rates range from 23 to 53 percent [22].
Hypothyroidism may also complicate long-term treatment with the tyrosine kinase inhibitors
sunitinib and (to a lesser extent) sorafenib. (See "Toxicity of molecularly targeted antiangiogenic
agents: Non-cardiovascular effects", section on 'Thyroid dysfunction'.)
Thyroid disorders are also common in patients undergoing immunotherapy with immune
checkpoint inhibitors. (See "Toxicities associated with immune checkpoint inhibitors", section on
'Endocrinopathies'.)
Because hypothyroidism is associated with poor surgical site healing, serum TSH and free T4
concentrations should be measured prior to surgery in patients who have received more than a
10 Gy total dose to the neck or are receiving treatment with sunitinib, sorafenib, or an immune
checkpoint inhibitor and who are not already being treated for hypothyroidism. Patients found
to be hypothyroid should receive supplemental thyroid hormone prior to surgery. (See
"Nonthyroid surgery in the patient with thyroid disease" and "Treatment of primary
hypothyroidism in adults".)
Carcinoid crisis — Carcinoid crisis is a life-threatening form of carcinoid syndrome that

develops in patients with serotonin-producing well-differentiated neuroendocrine tumors,
primarily those arising in the gastrointestinal tract (carcinoid tumors), and may be triggered by
tumor manipulation (palpation at the bedside, biopsy, or during surgery) or by induction of
anesthesia. Carcinoid crisis presumably arises because of the release of an overwhelming
amount of biologically active compounds, such as catecholamines, that are produced by the
tumor. Symptoms include flushing, diarrhea, tachycardia, arrhythmias, hypertension or
hypotension, bronchospasm, and delirium. (See "Clinical features of carcinoid syndrome".)
For patients undergoing surgery for metastatic neuroendocrine tumors who have a history of
carcinoid syndrome, prophylactic preoperative use of octreotide is optional, especially in those
who are already receiving a long-acting somatostatin analog, and almost certainly unnecessary
in patients without carcinoid syndrome. However, octreotide should be readily available during
any surgical procedure for use on an "as needed" basis in the event of hemodynamic
compromise. (See "Treatment of the carcinoid syndrome", section on 'Carcinoid crisis:
prevention and management'.)
Pheochromocytoma/paraganglioma surgery — Pheochromocytomas are rare

catecholamine-secreting neuroendocrine tumors that arise from chromaffin cells of the adrenal
medulla and the sympathetic ganglia (sometimes referred to as extra-adrenal catecholamine-
secreting paragangliomas or extra-adrenal pheochromocytomas). Some form of preoperative
pharmacologic preparation is indicated for all patients with catecholamine-secreting
neoplasms, including pheochromocytomas and paragangliomas. Preoperative medical therapy
(typically starting with pharmacologic alpha-adrenergic followed by beta-adrenergic blockade)
is aimed at controlling hypertension (including preventing a hypertensive crisis during surgery)
and ensuring adequate intravascular volume prior to surgery. (See "Treatment of
pheochromocytoma in adults", section on 'Medical preparation for surgery' and
"Paragangliomas: Treatment of locoregional disease", section on 'Medical preparation for
surgery'.)
HEMATOLOGIC STATUS
Hypercoagulability — A hypercoagulable state is common in patients with cancer, particularly

those with advanced disease and primary brain tumors, and may be due to increased plasma
levels of clotting factors, cytokines, or cancer procoagulant A, or to increased release of tissue
plasminogen activator. (See "Cancer-associated hypercoagulable state: Causes and
mechanisms".)
Hypercoagulability (leading to arterial [myocardial infarction and stroke] as well as venous

thrombosis) is also a potential side effect of cancer treatment with certain drugs (eg,
bevacizumab and other drugs that target the vascular endothelial growth factor, thalidomide,
lenalidomide) and drug combinations (such as bleomycin, cisplatin, and vinblastine). (See
"Multiple myeloma: Prevention of venous thromboembolism in patients receiving
immunomodulatory drugs (thalidomide, lenalidomide, and pomalidomide)" and "Toxicity of
molecularly targeted antiangiogenic agents: Cardiovascular effects", section on 'Arterial and
venous thromboembolism' and "Treatment-related toxicity in men with testicular germ cell
tumors", section on 'Thromboembolic events' and "Cancer-associated hypercoagulable state:
Causes and mechanisms", section on 'Therapy-related factors'.)
Perioperative venous thromboembolism (VTE) is more frequent in patients with known cancer
than in the general population, occurring in up to 40 percent of patients in clinical trials
employing venography for diagnosis. As a result, individuals with cancer should be considered
high risk for development of perioperative VTE. This increased risk is reflected in the Caprini
score for VTE in surgical patients, which assigns two points for the presence of malignancy
( table 4). (See "Risk and prevention of venous thromboembolism in adults with cancer",
section on 'Surgical patients' and "Treatment and prevention of venous thromboembolism in
patients with brain tumors", section on 'Primary prevention (VTE prophylaxis)'.)
Options for prophylaxis include mechanical methods (eg, pneumatic boots), low-dose
unfractionated heparin, low-molecular-weight heparin, or fondaparinux. Specific
recommendations for prophylactic treatment are available from expert groups and are
discussed elsewhere. (See "Risk and prevention of venous thromboembolism in adults with
cancer", section on 'Surgical patients' and "Treatment and prevention of venous
thromboembolism in patients with brain tumors", section on 'Incidence and risk factors'.)
Recommendations for patients who require anticoagulation and are also thrombocytopenic are
provided elsewhere. (See "Anticoagulation in individuals with thrombocytopenia", section on
'Cancer-associated VTE'.)
Anemia — Anemia is common in cancer patients, and it is frequently undertreated. Anemia is

associated with impaired performance status and poorer postoperative outcomes. In addition,
anemia is an independent predictor of poor prognosis in cancer patients [23-30]. Therefore,
patients who have undergone cancer treatment or who are at risk for anemia due to their
cancer should have a complete blood count with differential/platelets before surgery.
Iron deficiency commonly contributes to anemia in cancer patients, particularly in patients with
gastrointestinal malignancies [31]. If present, iron deficiency should be treated before surgery
to improve the patient's strength, endurance, and, possibly, quality of life, although it is unclear
whether or not treatment will reduce perioperative transfusion requirements [32-38]. In
addition to encouraging iron-rich foods ( table 5), oral iron supplementation and intravenous
iron replacement should be considered on an individual basis. Intravenous iron replacement
has become safer and is likely to more rapidly replete iron stores than oral iron [33,39-41].
There are no guidelines regarding which patients are most likely to benefit from intravenous
rather than only oral iron replacement. Additional clinical trials are needed in this area. (See
"Causes and diagnosis of iron deficiency and iron deficiency anemia in adults" and "Treatment
of iron deficiency anemia in adults", section on 'Perioperative'.)
The optimal approach for preoperative management of anemic patients who are not iron
deficient is debated. The use of erythropoietin-stimulating agents in the preoperative period
may increase thrombotic complications. Such agents may also stimulate neoplastic growth,
thereby increasing the risk of recurrence and of secondary cancers, such as transitional cell
cancers of the urinary tract. (See "Role of erythropoiesis-stimulating agents in the treatment of
anemia in patients with cancer", section on 'Issues related to thromboembolic risk' and "Role of
erythropoiesis-stimulating agents in the treatment of anemia in patients with cancer", section
on 'Should use be avoided in patients treated with curative intent?'.)
Blood transfusion might be appropriate for a severely anemic patient at risk for demand
ischemia of the heart, brain, or kidneys due to the expected physiologic stress of surgery
[42,43]. However, in patients undergoing cancer surgery, blood transfusions have been
independently associated with worse cancer outcomes and more postoperative complications
in many [30,44-50], but not all [23,51], studies. Whether this reflects an independent effect of
the transfusion or anemia severe enough to necessitate transfusion is simply a marker of the
severity of the underlying disease remains uncertain. Concerns about blood transfusion have
also included potential immunosuppression and the risk of transmitting or inducing cancer. At
least some data suggest that restricted transfusion practices may be associated with better
outcomes [52,53]. If the patient receives a blood transfusion prior to surgery, the goal should
be to transfuse the fewest possible units to achieve a hemoglobin level ≥7 g/dL.
Although autologous blood transfusion has the benefit of reducing the risk of an immune
reaction, it is more expensive, administratively more complicated and therefore more likely to
create an error in the process, and unlikely to be a consideration in cancer patients because
there is seldom time before surgery to allow the patient to recover from autologous donation.
Neutropenia and lymphopenia — Patients who are myelosuppressed as a result of

chemotherapy or hematologic malignancy are at increased risk of infection. The risk is higher
with longer durations of neutropenia and lymphopenia. (See "Overview of neutropenic fever
syndromes" and "Overview of neutropenia in children and adolescents".)
Whenever possible, nonemergency surgery should be postponed in neutropenic patients.

Postoperative fever is common, and if it develops in the setting of neutropenia, aggressive
diagnostic and therapeutic interventions are necessary. As discussed in more detail separately,
neutropenic fever in any setting requires the prompt administration of broad spectrum
antimicrobials. Even when neutropenia has resolved, patients receiving myelosuppressive
chemotherapy remain relatively immunocompromised for a period of time. (See "Fever in the
surgical patient" and "Treatment of neutropenic fever syndromes in adults with hematologic
malignancies and hematopoietic cell transplant recipients (high-risk patients)" and "Treatment
and prevention of neutropenic fever syndromes in adult cancer patients at low risk for
complications".)
Patients with hematologic cancers such as chronic lymphocytic leukemia have abnormal cellular
and humoral-mediated immune responses due to defects in immune effector cells, and they are
predisposed to infection, particularly if they are treated with purine analogs (eg, fludarabine),
chlorambucil, and alemtuzumab. These issues should be considered in the perioperative
period. (See "Risk of infections in patients with chronic lymphocytic leukemia" and "Prevention
of infections in patients with chronic lymphocytic leukemia".)
Thrombocytopenia — Thrombocytopenia can occur in cancer patients either as a result of the

malignancy or from treatment. In general, a platelet count of at least 50,000/microL is adequate
for most surgical procedures, but the specific procedure and the platelet function must also be
considered. Consider postponing surgery until the platelet count has recovered if the
thrombocytopenia is treatment related.
Drugs that can interfere with platelet function (aspirin, clopidogrel, nonsteroidal anti-
inflammatory agents) should be discontinued long enough prior to surgery to allow for
adequate recovery of platelet function. This period will depend on the specific antiplatelet
agent, the surgery, and the patient's other clinical conditions and medications. (See
"Preoperative assessment of bleeding risk" and "Platelet transfusion: Indications, ordering, and
associated risks", section on 'Platelet function disorders'.)
NEUROLOGIC STATUS
Paraneoplastic syndromes — Paraneoplastic syndromes that affect neuromuscular function

are relatively rare, but are of particular concern in the perioperative period because treatment
with anesthetic agents can exacerbate neuromuscular dysfunction, leading to respiratory

failure or delayed extubation. Although a wide variety of tumor types may be responsible, many
of these neuromuscular paraneoplastic syndromes arise in the setting of small cell lung cancer.
Treatment of the cancer may occasionally mitigate these symptoms. (See "Paraneoplastic
syndromes affecting spinal cord, peripheral nerve, and muscle".)
Screening for brain metastases — Routine imaging of the central nervous system is not
mandatory in patients with cancer prior to surgery. However, radiographic imaging of the brain
may be warranted in the setting of unexplained symptoms referable to the central nervous
system (CNS). Furthermore, if prophylactic anticoagulation is planned, radiographic screening
for brain metastases (preferably with magnetic resonance imaging [MRI]) should be pursued in
those patients whose tumors have a propensity to spread to the CNS and spontaneously bleed,
including melanoma, small cell carcinoma of the lung, choriocarcinoma, renal cell, breast,
adenocarcinoma of the lung, or thyroid cancer. Patients with other systemic cancers should also
be imaged if there are any symptoms suggesting brain metastasis (eg, headache, mental status
changes, seizures, other neurologic symptoms). The presence of untreated CNS metastases
represents a relative contraindication to systemic anticoagulation in this setting, while active
intracranial bleeding is an absolute contraindication. (See "Prevention of venous
thromboembolic disease in adult nonorthopedic surgical patients" and "Treatment and
prevention of venous thromboembolism in patients with brain tumors", section on 'Pre-
anticoagulation risk assessment'.)
Stroke risk in patients undergoing neck irradiation — Ischemic stroke can be a late
complication of neck irradiation, with multiple factors contributing to this risk, including carotid
artery stenosis, increased deposition of plaque, and pre-existing risk factors for cerebrovascular
disease, such as smoking. A high index of suspicion for carotid artery disease should be
maintained in patients who have received neck irradiation, particularly in conjunction with
chemotherapy for head and neck cancer. (See "Management of late complications of head and
neck cancer and its treatment", section on 'Carotid artery injury'.)
OTHER EFFECTS OF CHEMOTHERAPY
Hepatotoxicity — Several chemotherapeutic agents are potentially hepatotoxic. Although most

hepatotoxic effects are transient, if signs or symptoms suggest the development of
hepatotoxicity, then measure the prothrombin time as a test of adequate hepatic synthetic
function prior to surgery. (See "Chemotherapy hepatotoxicity and dose modification in patients
with liver disease: Conventional cytotoxic agents".)
Reactivation of viral hepatitis (particularly hepatitis B virus [HBV]) is a potential complication of

myelosuppressive chemotherapy, particularly in patients receiving rituximab and ofatumumab.
Patients who are positive for HBV surface antigen or for antibodies against HBV core antigen
(anti-HBc) should have liver biochemical tests measured prior to surgery. (See "Hepatitis B virus
reactivation associated with immunosuppressive therapy".)
Nephrotoxicity — Several chemotherapeutic agents are potentially nephrotoxic, particularly

cisplatin. For virtually all patients who have recently undergone chemotherapy, measure serum
blood urea nitrogen, creatinine, and electrolyte concentrations before surgery. (See "Cisplatin
nephrotoxicity" and "Chemotherapy nephrotoxicity and dose modification in patients with
kidney impairment: Conventional cytotoxic agents" and "Chemotherapy nephrotoxicity and
dose modification in patients with kidney impairment: Molecularly targeted agents and
immunotherapies".)
Wound healing — Impaired wound healing is a well-described complication of certain

chemotherapy agents, particularly antiangiogenic agents targeting the vascular endothelial
growth factor. Because of the long half-life of bevacizumab (20 days), it is generally
recommended that at least 28 days (preferably six to eight weeks) should elapse between a
dose of bevacizumab and major surgery when feasible. Because of their shorter half-lives, some
suggest that orally active small molecular antiangiogenic tyrosine kinase inhibitors (eg,
sunitinib, sorafenib, pazopanib, vandetanib, cabozantinib) be stopped for at least one week (48
hours for agents with a short half-life such as axitinib) before surgery and not reinitiated until
adequate wound healing has occurred. (See "Toxicity of molecularly targeted antiangiogenic
agents: Non-cardiovascular effects", section on 'Delayed wound healing' and "Potentially
resectable colorectal cancer liver metastases: Integration of surgery and chemotherapy",
section on 'Issues related to bevacizumab'.)
IMMUNIZATIONS PRIOR TO SPLENECTOMY
The spleen is the dominant site for the production of immunoglobulin M (IgM) antibodies
required for opsonizing encapsulated pathogens. Thus, for patients in whom concomitant
splenectomy is anticipated (eg, during resection of a distal pancreatic cancer), patients should
undergo appropriately timed preoperative immunization against Streptococcus pneumoniae
(pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae type b. If
vaccination was not possible prior to surgery, or unanticipated splenectomy was performed,
the patient should be vaccinated postoperatively. Vaccination recommendations for asplenic
patients are presented elsewhere ( table 6). (See "Prevention of infection in patients with
impaired splenic function" and "Elective (diagnostic or therapeutic) splenectomy", section on

'Vaccinations'.)
SUMMARY
The surgical risk for most cancer patients is comparable to that of patients without cancer and
should be managed similarly. However, the following should be considered in the preoperative
evaluation of patients with cancer:
● Nutrition – Optimize nutritional status prior to surgery. For all cancer patients for whom
surgery is being contemplated, regardless of time to operation, consultation with a
nutritionist should be obtained if possible. (See 'Nutrition' above.)
● Pain control – Address postoperative pain control during the preoperative evaluation of
patients who chronically take opioids because these patients are likely to require greater
than usual doses of medication for postoperative pain control. (See 'Pain' above.)
● Cardiopulmonary issues
• Patients who have received radiation therapy (RT) to fields that include the heart are at
increased risk for premature coronary artery disease, cardiac conduction disease, and
valvular heart disease, and should be screened for heart disease clinically and with a
12-lead electrocardiogram (ECG). Obtain additional cardiac testing if indicated. (See
'Cardiovascular status' above.)
• Patients who have received anthracycline or trastuzumab chemotherapy are at risk for
heart failure, and should be screened for heart failure clinically and with a 12-lead ECG.
Obtain additional cardiac testing if indicated. (See 'Cardiac toxicity from chemotherapy'
above.)
• Several chemotherapy drugs prolong the QT interval, which may increase the risk for
potentially fatal arrhythmias ( table 2). Correct electrolyte abnormalities
preoperatively and avoid other QT-prolonging drugs or strong inhibitors of cytochrome
P450 3A4 (CYP3A4) ( table 3).
• Patients with symptomatic pericardial effusions, cardiac tamponade, or constrictive

pericarditis should be managed prior to surgery. (See 'Pericardial disease' above.)
• Patients with mass lesions that could compromise the upper central airway are at
increased risk for perioperative respiratory failure, and should have airway patency
assessed preoperatively. (See 'Cardiopulmonary mass effects' above.)
Patients with a mediastinal mass are also at increased risk for perioperative
cardiopulmonary failure. Before surgery, obtain chest cross-sectional imaging
echocardiography, and flow-volume loop measurements. Those with evidence of
cardiac, vascular, or airway compression require special perioperative management.
(See 'Cardiopulmonary mass effects' above.)
• Treatment with supplemental inhaled oxygen several years after bleomycin therapy
can also cause lung damage. Before surgery, carefully assess the pulmonary function
of patients who have ever received bleomycin, and minimize the use of supplemental
inhaled oxygen and intravenous fluids both during and after surgery. (See "Strategies
to reduce postoperative pulmonary complications in adults".)
● Endocrine and electrolyte issues
• If time and facilities permit, assess patients at risk for adrenal insufficiency with
measurement of an early morning serum cortisol concentration or an
adrenocorticotropin stimulation test. Otherwise, consider treating high-risk patients
with an empiric perioperative stress-dose glucocorticoid. (See 'Adrenal insufficiency'
above and "The management of the surgical patient taking glucocorticoids" and
"Treatment of adrenal insufficiency in adults".)
• Measure serum thyroid stimulating hormone and free T4 concentrations in patients

who have ever received neck RT or who have received sunitinib or sorafenib for more
than a few weeks, and correct hypothyroidism prior to surgery. Maintain a high clinical
index of suspicion for radiation-induced carotid artery stenosis. (See 'Hypothyroidism'
above and 'Stroke risk in patients undergoing neck irradiation' above.)
• Preoperative pharmacologic preparation is indicated for all patients with

catecholamine-secreting neoplasms, such as well-differentiated metastatic
neuroendocrine neoplasms of the gastrointestinal tract (carcinoids) or
pheochromocytoma/paraganglioma. (See 'Carcinoid crisis' above and
'Pheochromocytoma/paraganglioma surgery' above.)
• Before surgery, screen all patients who have systemic malignancy with serum blood
urea nitrogen, creatinine, sodium, and calcium concentrations, and with a complete
blood count. Preoperative hyponatremia is associated with worse outcomes; avoid
hypotonic intravenous solutions, and closely monitor the patient in the postoperative
period. (See 'Hyponatremia' above.)
• Patients with cancer often have a hypercoagulable state (which may be due to the
cancer or its treatment), and they are at high risk for perioperative venous
thromboembolism; prophylaxis is warranted for most patients in the perioperative
period. (See 'Hypercoagulability' above.)
● Hematologic issues
• When feasible, postpone surgery to allow recovery from chemotherapy-induced

neutropenia and thrombocytopenia. (See 'Neutropenia and lymphopenia' above.)
• If present, treat iron deficiency before surgery. Depending on the cause and the timing
of surgery, it might be necessary to give the patient a blood transfusion to at least
achieve a hemoglobin level of 7 g/dL, although blood-sparing techniques are
preferable. (See 'Anemia' above.)
● Other
• Reactivation of viral hepatitis (particularly hepatitis B virus [HBV]) is a potential

complication of myelosuppressive chemotherapy, particularly rituximab and
ofatumumab. Patients who are positive for HBV surface antigen or for antibodies
against HBV core antigen should have liver biochemical tests measured prior to
surgery. (See 'Hepatotoxicity' above.)
• Impaired wound healing is a well-described complication of certain chemotherapy

agents, particularly antiangiogenic agents At least 28 days (preferably six to eight
weeks) should elapse between a dose of bevacizumab and major surgery, when
feasible. Orally active small molecular antiangiogenic tyrosine kinase inhibitors should
be stopped at least one week before surgery. (See 'Wound healing' above.)
• For patients in whom concomitant splenectomy is anticipated (eg, resection of a distal

pancreatic cancer), preoperative immunization against S. pneumoniae (pneumococcus),
N. meningitidis (meningococcus), and H. influenzae type b is indicated. (See
'Immunizations prior to splenectomy' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Ramesh HS, Pope D, Gennari R, Audisio RA. Optimising surgical management of elderly
cancer patients. World J Surg Oncol 2005; 3:17.
2. Morton DL, Kagan AR, Roberts WC, et al. Pericardiectomy for radiation-induced pericarditis
with effusion. Ann Thorac Surg 1969; 8:195.
3. Brosius FC 3rd, Waller BF, Roberts WC. Radiation heart disease. Analysis of 16 young (aged
15 to 33 years) necropsy patients who received over 3,500 rads to the heart. Am J Med
1981; 70:519.
4. Stewart JR, Fajardo LF. Radiation-induced heart disease. Clinical and experimental aspects.
Radiol Clin North Am 1971; 9:511.
5. Carlson RG, Mayfield WR, Normann S, Alexander JA. Radiation-associated valvular disease.
Chest 1991; 99:538.
6. Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE. Radiation-associated cardiovascular
disease. Crit Rev Oncol Hematol 2003; 45:55.
7. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from
the American Heart Association: a guideline from the American Heart Association
Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on
Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group. Circulation 2007; 116:1736.
8. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular
heart disease: focused update on infective endocarditis: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by
the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography
and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:887.
9. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of
infective endocarditis: The Task Force for the Management of Infective Endocarditis of the
European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-
Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart
J 2015; 36:3075.
10. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014
AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report
of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. J Am Coll Cardiol 2017; 70:252.
11. Plummer C, Henderson RD, O'Sullivan JD, Read SJ. Ischemic stroke and transient ischemic
attack after head and neck radiotherapy: a review. Stroke 2011; 42:2410.
12. Von Hoff DD, Rozencweig M, Piccart M. The cardiotoxicity of anticancer agents. Semin
Oncol 1982; 9:23.
13. Jensen BV, Skovsgaard T, Nielsen SL. Functional monitoring of anthracycline cardiotoxicity:
a prospective, blinded, long-term observational study of outcome in 120 patients. Ann
Oncol 2002; 13:699.
14. Mackie AM, Watson CB. Anaesthesia and mediastinal masses. A case report and review of
the literature. Anaesthesia 1984; 39:899.
15. Mathes DD, Bogdonoff DL. Preoperative evaluation of the cancer patient. In: Surgical Probl
ems Affecting the Patient with Cancer, Lefor AT (Ed), Lippincott-Raven, Philadelphia 1996. p.
273.
16. Klein DS, Wilds PR. Pulmonary toxicity of antineoplastic agents: anaesthetic and
postoperative implications. Can Anaesth Soc J 1983; 30:399.
17. Leung AA, McAlister FA, Rogers SO Jr, et al. Preoperative hyponatremia and perioperative
complications. Arch Intern Med 2012; 172:1474.
18. Vassalotti JA, DuPree E. Preoperative hyponatremia: an opportunity for intervention? Arch
Intern Med 2012; 172:1482.
19. Yeung S-CJ, Lazo-Diaz G, Gagel RF. Metabolic and endocrine emergencies. In: Oncologic Em
ergencies, Yeung SCJ, Escalante C (Eds), BC Decker, Inc, Ontario 2002. p.103.
20. Hancock SL, Cox RS, McDougall IR. Thyroid diseases after treatment of Hodgkin's disease.
N Engl J Med 1991; 325:599.
21. Peerboom PF, Hassink EA, Melkert R, et al. Thyroid function 10-18 years after mantle field
irradiation for Hodgkin's disease. Eur J Cancer 1992; 28A:1716.
22. Boomsma MJ, Bijl HP, Langendijk JA. Radiation-induced hypothyroidism in head and neck
cancer patients: a systematic review. Radiother Oncol 2011; 99:1.
23. Chalfin HJ, Frank SM, Feng Z, et al. Allogeneic versus autologous blood transfusion and
survival after radical prostatectomy. Transfusion 2014; 54:2168.
24. Bruns ERJ, Borstlap WA, van Duijvendijk P, et al. The Association of Preoperative Anemia
and the Postoperative Course and Oncological Outcome in Patients Undergoing Rectal
Cancer Surgery: A Multicenter Snapshot Study. Dis Colon Rectum 2019; 62:823.
25. Fowler AJ, Ahmad T, Phull MK, et al. Meta-analysis of the association between preoperative
anaemia and mortality after surgery. Br J Surg 2015; 102:1314.
26. Wilson MJ, van Haaren M, Harlaar JJ, et al. Long-term prognostic value of preoperative
anemia in patients with colorectal cancer: A systematic review and meta-analysis. Surg
Oncol 2017; 26:96.
27. van Halteren HK, Houterman S, Verheij CD, et al. Anaemia prior to operation is related with
poorer long-term survival in patients with operable rectal cancer. Eur J Surg Oncol 2004;
30:628.
28. Lee H, Park HC, Park W, et al. Negative impact of pretreatment anemia on local control
after neoadjuvant chemoradiotherapy and surgery for rectal cancer. Radiat Oncol J 2012;
30:117.
29. Liu Y, Bai YP, Zhou ZF, et al. Preoperative anemia as a prognostic factor in patients with lung
cancer: a systematic review and meta-analysis of epidemiological studies. J Cancer 2019;
10:2047.
30. Baumeister P, Canis M, Reiter M. Preoperative anemia and perioperative blood transfusion
in head and neck squamous cell carcinoma. PLoS One 2018; 13:e0205712.
31. Wilson MJ, Dekker JWT, Harlaar JJ, et al. The role of preoperative iron deficiency in colorectal
cancer patients: prevalence and treatment. Int J Colorectal Dis 2017; 32:1617.
32. Quinn EM, Meland E, McGinn S, Anderson JH. Correction of iron-deficiency anaemia in
colorectal surgery reduces perioperative transfusion rates: A before and after study. Int J
Surg 2017; 38:1.
33. Keeler BD, Simpson JA, Ng O, et al. Randomized clinical trial of preoperative oral versus
intravenous iron in anaemic patients with colorectal cancer. Br J Surg 2017; 104:214.
34. Richards T, Baikady RR, Clevenger B, et al. Preoperative intravenous iron to treat anaemia
before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial.
Lancet 2020; 396:1353.
35. Schack A, Berkfors AA, Ekeloef S, et al. The Effect of Perioperative Iron Therapy in Acute
Major Non-cardiac Surgery on Allogenic Blood Transfusion and Postoperative Haemoglobin
Levels: A Systematic Review and Meta-analysis. World J Surg 2019; 43:1677.
36. Triphaus C, Judd L, Glaser P, et al. Effectiveness of Preoperative Iron Supplementation in
Major Surgical Patients With Iron Deficiency: A Prospective Observational Study. Ann Surg
2021; 274:e212.
37. Ng O, Keeler BD, Mishra A, et al. Iron therapy for preoperative anaemia. Cochrane
Database Syst Rev 2019; 12:CD011588.
38. Borstlap WAA, Buskens CJ, Tytgat KMAJ, et al. Multicentre randomized controlled trial
comparing ferric(III)carboxymaltose infusion with oral iron supplementation in the
treatment of preoperative anaemia in colorectal cancer patients. BMC Surg 2015; 15:78.
39. Wilson MJ, Dekker JWT, Buettner S, et al. The effect of intravenous iron therapy on long-
term survival in anaemic colorectal cancer patients: Results from a matched cohort study.
Surg Oncol 2018; 27:192.
40. Tang GH, Dhir V, Scheer AS, et al. Intravenous iron versus oral iron or observation for
gastrointestinal malignancies: a systematic review. Eur J Gastroenterol Hepatol 2019;
31:799.
41. Busti F, Marchi G, Ugolini S, et al. Anemia and Iron Deficiency in Cancer Patients: Role of
Iron Replacement Therapy. Pharmaceuticals (Basel) 2018; 11.
42. Fischer D, Neb H, Choorapoikayil S, et al. Red blood cell transfusion and its alternatives in
oncologic surgery-A critical evaluation. Crit Rev Oncol Hematol 2019; 134:1.
43. Tzounakas VL, Seghatchian J, Grouzi E, et al. Red blood cell transfusion in surgical cancer
patients: Targets, risks, mechanistic understanding and further therapeutic opportunities.
Transfus Apher Sci 2017; 56:291.
44. Kwon HY, Kim BR, Kim YW. Association of preoperative anemia and perioperative allogenic
red blood cell transfusion with oncologic outcomes in patients with nonmetastatic
colorectal cancer. Curr Oncol 2019; 26:e357.
45. Grasso M, Pacella G, Sangiuliano N, et al. Gastric cancer surgery: clinical outcomes and
prognosis are influenced by perioperative blood transfusions. Updates Surg 2019; 71:439.
46. Tsivian M, Abern MR, Tsivian E, et al. Effect of blood transfusions on oncological outcomes
of surgically treated localized renal cell carcinoma. Urol Oncol 2018; 36:362.e1.
47. Lopez-Aguiar AG, Ethun CG, McInnis MR, et al. Association of perioperative transfusion with
survival and recurrence after resection of gallbladder cancer: A 10-institution study from
the US Extrahepatic Biliary Malignancy Consortium. J Surg Oncol 2018; 117:1638.
48. Boshier PR, Ziff C, Adam ME, et al. Effect of perioperative blood transfusion on the long-
term survival of patients undergoing esophagectomy for esophageal cancer: a systematic
review and meta-analysis. Dis Esophagus 2018; 31.
49. Abe T, Amano H, Hanada K, et al. Perioperative Red Blood Cell Transfusion Is Associated
with Poor Long-term Survival in Pancreatic Adenocarcinoma. Anticancer Res 2017; 37:5863.
50. Newhook TE, Prakash LR, Soliz J, et al. Perioperative blood transfusions and survival in
resected pancreatic adenocarcinoma patients given multimodality therapy. J Surg Oncol
2021; 124:1381.
51. Manning-Geist BL, Alimena S, Del Carmen MG, et al. Infection, thrombosis, and oncologic
outcome after interval debulking surgery: Does perioperative blood transfusion matter?
Gynecol Oncol 2019; 153:63.
52. Towe CW, Gulack BC, Kim S, et al. Restrictive Transfusion Practices After Esophagectomy
Are Associated With Improved Outcome: A Review of the Society of Thoracic Surgeons
General Thoracic Database. Ann Surg 2018; 267:886.
53. Ozben V, Stocchi L, Ashburn J, et al. Impact of a restrictive vs liberal transfusion strategy on
anastomotic leakage and infectious complications after restorative surgery for rectal
cancer. Colorectal Dis 2017; 19:772.
Topic 2793 Version 28.0
GRAPHICS
Multiple-hit hypothesis for cancer deconditioning
Multiple-hit hypothesis for cancer deconditioning.
Reprinted by permission from: Springer: Current Anesthesiology Reports. Sahai SK, Ismail H. Perioperative implications of neoadjuvan
therapies and optimization strategies for cancer surgery. Curr Anesthesiol Rep 2015; 4:305. Copyright © 2015.
https://link.springer.com/journal/40140.
Graphic 113780 Version 6.0
Approximate dose conversions for commonly used opioids (refer to

important note below)
Approximate dose conversions for commonly used opioids (refer to important notes
below)
Hydromorphone Fentanyl
Morphine Oxycodone
(Dilaudid) transdermal*
IV Oral IV Oral
Oral (mg/day) Patch (mcg/hour)
(mg/day) (mg/day) (mg/day) (mg/day)
5 15 0.75 3.5 10 NA
8.5 25 1.25 6.5 15 12
10 30 1.5 7.5 20 12
17 50 2.5 12.5 30 25
33 100 5 25 65 50
50 150 7.5 37.5 100 75
67 200 10 50 130 100
83 250 12.5 62.5 165 125
100 300 15 75 200 150
117 350 17.5 87.5 230 175
133 400 20 100 265 200
150 450 22.5 112.5 300 225
167 500 25 125 330 250
183 550 27.5 137.5 360 275
200 600 30 150 400 300
Conversion ratios to determine daily total ORAL morphine milligram equivalent

(MME)
Drug Approximate Approximate Conversion ratio

equivalent oral dose equivalent IV or to determine
subcutaneous daily total ORAL
dose morphine
milligram
equivalent (MME)
Morphine 30 mg 10 mg Parenteral
morphine to oral
morphine: 1:3
Fentanyl Not available 0.1 mg (100 mcg) Parenteral

fentanyl to oral
morphine: 1:300
Hydrocodone 30 mg Not available Oral

hydrocodone to
oral morphine:
1:1 ¶
Hydromorphone 7.5 mg 1.5 mg Oral

hydromorphone
to oral
morphine: 1:4
Parenteral
hydromorphone
to oral
morphine: 1:20
Oxycodone 20 mg Not available Oral oxycodone

to oral
morphine: 1:1.5
Oxymorphone 10 mg 1 mg Oral
oxymorphone to
oral morphine:
1:3
Parenteral
oxymorphone to
oral morphine:
1:30
Important notes:
The doses included here provide a starting point for the purpose of comparing and switching
different opioids during maintenance therapy; these are not recommended doses for the
initiation of opioid therapy.
Equianalgesic conversions serve only as a general guide to estimate opioid dose equivalents.
When switching to a new opioid, the initial daily dose for the new opioid determined by using the
conversions in the first part of this table should be further reduced by 25 to 50% to adjust for
lack of complete mu receptor cross-tolerance (except when switching to methadone, which
requires a 75 to >90% reduction; refer to UpToDate topics on cancer pain management with
opioids, optimizing analgesia). In contrast, when switching between intravenous and oral
administration of the same opioid, an empiric reduction of the equianalgesic dose estimate
shown above is generally not necessary.
The calculated starting dose of the new opioid or new route of administration will require
monitoring and further titration after making the conversion. For a review of multiple factors that
must be considered for safely individualizing conversion of opioid analgesia in patients with
cancer, refer to UpToDate topics on cancer pain management with opioids, optimizing analgesia.
The approximate equivalences have been rounded. Further rounding may be necessary for
available tablet strengths.
The second part of this table provides conversion factors to assess the total daily oral morphine
milligram equivalent (MME) dose. Total daily oral MME dose >50 mg is one factor among several
that can help identify patients who may be at higher risk for overdose and may benefit from
closer monitoring and coprescription of naloxone. A high daily MME dose may also be useful for
identifying tolerance, and can suggest that a patient may benefit from opioid rotation. For
further information refer to UpToDate content on chronic pain management.
IV: intravenous; mcg: microgram.
* Suggested doses for conversion to transdermal fentanyl from other opioids are less conservative
than recommendations in the United States product labeling. The recommendations in this table are
based on guidance available at experienced centers.
¶ Wide interpatient variability in response.
Courtesy of Kathleen Broglio, DNP, MN, ANP-BC, ACHPN and Russell K Portenoy, MD.
Additional data from:

1. National Comprehensive Cancer Network. Adult Cancer Pain, Version 2.2021.
2. Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
Stepwise approach to perioperative cardiac assessment for

CAD
ACS: acute coronary syndrome; CABG: coronary artery bypass graft surgery; CAD:
coronary artery disease; CPG: clinical practice guideline; DASI: Duke Activity Status
Index; GDMT: guideline-directed therapy; HF: heart failure; MACE: major adverse
cardiac event; MET: metabolic equivalent; NB: no benefit; NSQIP: National Surgical
Quality Improvement Program; PCI: percutaneous coronary intervention; RCRI:
Revised Cardiac Risk Index; STEMI: ST elevation myocardial infarction; UA/NSTEMI:

unstable angina/non-ST elevation myocardial infarction; VHD: valvular heart
disease.
Reproduced from: Fleisher LA, Fleischmann KE, Auerbach AD. 2014 ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am
Coll Cardiol 2014. [Epub ahead of print]. Illustration used with the permission of Elsevier Inc. All rights
reserved.
Some reported causes and potentiators of the long QT syndrome*
Congenital
Jervell and Lange-Nielsen syndrome (including "channelopathies")

Romano-Ward syndrome
Idiopathic
Acquired
Metabolic disorders
Hypokalemia
Hypomagnesemia
Hypocalcemia
Starvation
Anorexia nervosa
Liquid protein diets
Hypothyroidism
Bradyarrhythmias
Sinus node dysfunction
AV block: Second or third degree
Analgesic, anesthetic, and sedative drugs

Anesthetic/sedative:
Moderate risk: Propofol
Low risk: Dexmedetomidine ¶
Opioids:
High risk: Methadone
Low risk: Buprenorphine Δ
Androgen deprivation therapy (GnRH agonist/antagonist therapy or bilateral surgical orchiectomy)
Antianginal drugs
Low risk: Ranolazine (due to bradycardia)
Antiarrhythmic drugs
High risk: Amiodarone ◊ , disopyramide, dofetilide, dronedarone, ibutilide, procainamide,
quinidine, sotalol, vernakalant §
Moderate risk: Flecainide, pilsicainide § , propafenone
Anticholinergic drugs (antimuscarinics)

Low risk: Solifenacin
Antihistamines
High risk: Astemizole ¥ , terfenadine ¥
Lower risk: Bilastine § , hydroxyzine
Antimicrobials
Antimalarial:
High risk: Delamanid § , quinidine, quinine
Moderate risk: Chloroquine, halofantrine, piperaquine
Lower risk: Artemether-lumefantrine, hydroxychloroquine (rare reports, noted in labeling)
Antiparasitic and antiprotozoal:
Moderate risk: Fexinidazole, meglumine antimoniate
Antituberculous:
High risk: Bedaquiline
Azole antifungals:
Moderate risk: Fluconazole, voriconazole
Low to moderate risk: Itraconazole, ketoconazole (systemic)
Clofazimine (moderate risk)
Fluoroquinolones (systemic):
Moderate risk: Gemifloxacin § , levofloxacin, moxifloxacin, sparfloxacin §
Low to moderate risk: Ciprofloxacin, norfloxacin, ofloxacin
Foscarnet (low to moderate risk)
HIV antiretrovirals:
Moderate risk: Saquinavir
Low to moderate risk: Efavirenz, fostemsavir, lopinavir-ritonavir, rilpivirine
Macrolide antibiotics:
Moderate risk: Azithromycin, clarithromycin, erythromycin
Low to moderate risk: Roxithromycin, telithromycin
Metronidazole (low to moderate risk)
Pentamidine (IV) (moderate risk)
Telavancin (low to moderate risk)
Triclabendazole (low to moderate risk)
Antineoplastic drugs
High risk: Adagrasib, arsenic trioxide, ivosidenib, lenvatinib, mobocertinib, selpercatinib,
vandetanib
Moderate risk: Capecitabine, ceritinib, crizotinib, dabrafenib, dasatinib, encorafenib,
floxuridine, fluorouracil (systemic), gilteritinib, inotuzumab ozogamicin, midostaurin, nilotinib,
osimertinib, pazopanib, ribociclib, sunitinib, toremifene, vemurafenib
Lower risk: Bosutinib, eribulin, glasdegib, lapatinib, oxaliplatin, pacritinib, panobinostat,
romidepsin, sorafenib, tamoxifen, vorinostat
Bronchodilators (beta-2 agonists)

Moderate risk: Terbutaline
Lower risk: Albuterol, arformoterol, formoterol, indacaterol, levalbuterol, olodaterol, salmeterol,
vilanterol
Diuretics
Via electrolyte changes (especially hypokalemia or hypomagnesemia)
Gastrointestinal drugs
Antidiarrheal: Loperamide ‡ in overdose (lower risk)
Antiemetics:
Moderate risk: Droperidol, ondansetron (risk with IV use greater than oral)
Low to moderate risk: Amisulpride (IV antiemetic dose), dolasetron, granisetron,
hydroxyzine, tropisetron §
Promotility:
High risk: Cisapride (restricted availability)
Moderate risk: Domperidone §
Low to moderate risk (rare reports): Metoclopramide
Proton pump inhibitors: ‡ Chronic use leading to hypomagnesemia (rare)
Neurologic drugs
Low to moderate risk: Apomorphine, deutetrabenazine, donepezil, ezogabine, fingolimod,
ozanimod † , pimavanserin, ponesimod, tetrabenazine
Oxytocic drugs
Moderate risk: Carbetocin § , oxytocin
Psychotropic drugs
Antidepressants:
Selective serotonin reuptake inhibitors (SSRIs), serotonin modulators, and atypical agents:
Moderate risk: Citalopram, escitalopram
Low to moderate risk: Fluoxetine, sertraline, trazodone
Low risk: Mirtazapine
Tricyclic and tetracyclic antidepressants (TCAs):**
Moderate risk: Clomipramine, doxepin, and imipramine
Antipsychotics:
High risk: Chlorpromazine, IV haloperidol, sertindole § , ziprasidone
Moderate risk: Amisulpride (oral) § , clozapine, flupentixol § , haloperidol (oral), olanzapine,
pimozide, quetiapine, risperidone, thioridazine
Low to moderate risk: Asenapine, iloperidone, paliperidone, periciazine § , pimavanserin
Others:
Low to moderate risk: Atomoxetine
Low risk: Dexmedetomidine sublingual film ¶
Vasodilator drugs
High risk: Bepridil ¥
Other drugs
High risk: Levoketoconazole, papaverine (intracoronary)
Moderate risk: Etelcalcetide, gadobenate dimeglumine, lofexidine, probucol ¥
Low to moderate risk: Alfuzosin, anagrelide, cocaine (topical), eliglustat, mifepristone,

pasireotide, voclosporin
Herbs: Cinchona (contains quinine), licorice extract (glycyrrhizin) in overuse leading to electrolyte
abnormalities
Other factors
Myocardial ischemia or infarction, especially with prominent T-wave inversions
Intracranial disease
HIV infection
Hypothermia
Toxic exposure: Organophosphate insecticides
This is not a complete list of all corrected QT interval (QTc)-prolonging drugs and does not include
drugs with either a minor degree or isolated association(s) with QTc prolongation that appear to be
safe in most patients but may need to be avoided in patients with congenital long QT syndrome
depending upon clinical circumstances. A more complete list of such drugs is available at the
CredibleMeds website. For clinical use and precautions related to medications and drug interactions,
refer to the UpToDate topic review of acquired long QT syndrome discussion of medications and the
Lexicomp drug interactions tool.
AV: atrioventricular; IV: intravenous.
* Classifications provided by Lexicomp according to US Food & Drug Administration guidance:

Clinical Evaluation of QT/QTc Interval Prolongation and Proarrhythic Potential for Non-
Antiarrhythmic Drugs – Questions and Answers; Guidance for Industry US Food and Drug
Administration, June 2017 (revision 2) available at:
https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UC
M073161.pdf with additional data from CredibleMeds QT drugs list [1,2] . The use of other
classification criteria may lead to some agents being classified differently by other sources.
¶ The United States FDA labeling for the sublingual preparation of dexmedetomidine warns against
use in patients at elevated risk for QTc prolongation. Both intravenous (ie, sedative) and sublingual
formulations of dexmedetomidine have a low risk of QTc prolongation and have not been implicated
in TdP.
Δ Rarely associated with significant QTc prolongation at usual doses for treatment of opioid use
disorder, making buprenorphine a suitable alternative for patients with methadone-associated QTc
prolongation. Refer to UpToDate clinical topic reviews.
◊ In contrast with other class III antiarrhythmic drugs, amiodarone is rarely associated with
torsades de pointes; refer to accompanying text within UpToDate topic reviews of acquired long QT
syndrome.
§ Not available in the United States.
¥ Withdrawn from market in most countries due to adverse cardiovascular effects.
‡ Over-the-counter; available without a prescription.
† Not associated with significant QTc prolongation in healthy persons. Refer to UpToDate clinical
topic for potential adverse cardiovascular (CV) effects in patients with CV disease.
** Other cyclic antidepressants may also prolong the QT interval; refer to UpToDate clinical topic on
cyclic antidepressant pharmacology, side effects, and separate UpToDate topic on tricyclic
antidepressant poisoning.
Data from:
1. Lexicomp Online. Copyright ©1978-2023 Lexicomp, Inc. All Rights Reserved.
2. CredibleMeds QT drugs list website sponsored by Science Foundation of the University of Arizona. Available at
http://crediblemeds.org/.
Cytochrome P450 3A (including 3A4) inhibitors and inducers
Strong inhibitors Moderate Strong inducers Moderate inducers

inhibitors
Adagrasib Amiodarone* Apalutamide Bexarotene

Atazanavir Aprepitant Carbamazepine Bosentan
Ceritinib Berotralstat Enzalutamide Cenobamate
Clarithromycin Cimetidine* Fosphenytoin Dabrafenib
Cobicistat and Conivaptan Lumacaftor Dexamethasone ¶
cobicistat- Crizotinib Lumacaftor- Dipyrone
containing Cyclosporine* ivacaftor Efavirenz
coformulations Mitotane
Diltiazem Elagolix, estradiol,
Darunavir Phenobarbital and norethindrone
Duvelisib
Idelalisib Phenytoin therapy pack Δ
Dronedarone
Indinavir Primidone Eslicarbazepine
Erythromycin
Itraconazole Rifampin Etravirine
Fedratinib
Ketoconazole (rifampicin) Lorlatinib
Fluconazole
Levoketoconazole Mitapivat
Fosamprenavir
Lonafarnib Modafinil
Fosaprepitant*
Lopinavir Nafcillin
Fosnetupitant-
Mifepristone palonosetron Pexidartinib
Nefazodone Grapefruit juice Rifabutin
Nelfinavir Imatinib Rifapentine
Nirmatrelvir- Isavuconazole Sotorasib
ritonavir (isavuconazonium St. John's wort
Ombitasvir- sulfate)
paritaprevir- Lefamulin
ritonavir
Letermovir
Ombitasvir-
Netupitant
paritaprevir-
Nilotinib
ritonavir plus
Ribociclib
dasabuvir
Schisandra
Posaconazole
Ritonavir and Verapamil
ritonavir-containing
coformulations
Saquinavir
Telithromycin
Tucatinib
Voriconazole
For drug interaction purposes, the inhibitors and inducers of CYP3A metabolism listed above can
alter serum concentrations of drugs that are dependent upon the CYP3A subfamily of liver
enzymes, including CYP3A4, for elimination or activation.
These classifications are based upon US Food and Drug Administration (FDA) guidance. [1,2]
Other sources may use a different classification system resulting in some agents being classified
differently.
Data are for systemic drug forms. Degree of inhibition or induction may be altered by dose,
method, and timing of administration.
Weak inhibitors and inducers are not listed in this table with exception of a few examples.
Clinically significant interactions can occasionally occur due to weak inhibitors and inducers (eg,
target drug is highly dependent on CYP3A4 metabolism and has a narrow therapeutic index).
Accordingly, specific interactions should be checked using a drug interaction program such as
the Lexicomp drug interactions program included within UpToDate.
Refer to UpToDate topics on specific agents and indications for further details.
* Classified as a weak inhibitor of CYP3A4 according to FDA system. [1]
¶ Classified as a weak inducer of CYP3A4 according to FDA system. [1]
Δ The fixed-dose combination therapy pack taken in the approved regimen has moderate CYP3A4
induction effects. When elagolix is used as a single agent, it is a weak CYP3A4 inducer.
Norethindrone and estradiol are not CYP3A4 inducers.
Data from: Lexicomp Online (Lexi-Interact). Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
References:
1. Clinical Drug Interaction Studies — Cytochrome P450 Enzyme- and Transporter-Mediated Drug Interactions Guidance
for Industry (January 2020) available at: https://www.fda.gov/regulatory-information/search-fda-guidance-
documents/clinical-drug-interaction-studies-cytochrome-p450-enzyme-and-transporter-mediated-drug-interactions.
2. US Food & Drug Administration. Drug Development and Drug Interactions: Table of Substrates, Inhibitors and
Inducers. Available at: FDA.gov website.
Modified Caprini risk assessment model for VTE in general surgical patients
Risk score
1 point 2 points 3 points 5 points
Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)
Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
BMI >25 kg/m 2 Major open surgery Family history of VTE Hip, pelvis, or leg
(>45 minutes) fracture
Swollen legs Laparoscopic surgery Factor V Leiden Acute spinal cord injury
(>45 minutes) (<1 month)
Varicose veins Malignancy Prothrombin 20210A
Pregnancy or Confined to bed (>72 Lupus anticoagulant

postpartum hours)
History of unexplained Immobilizing plaster Anticardiolipin

or recurrent cast antibodies
spontaneous abortion
Oral contraceptives or Central venous access Elevated serum

hormone replacement homocysteine
Sepsis (<1 month) Heparin-induced

thrombocytopenia
Serious lung disease, Other congenital or

including pneumonia acquired
(<1 month) thrombophilia
Abnormal pulmonary
function
Acute myocardial
infarction
Congestive heart
failure (<1 month)
History of
inflammatory bowel
disease
Medical patient at bed

rest
Interpretation
Estimated VTE risk

in the absence of
Surgical risk pharmacologic or
Score
category* mechanical
prophylaxis
(percent)
Very low (see text for 0 <0.5

definition)
Low 1 to 2 1.5
Moderate 3 to 4 3.0
High ≥5 6.0
VTE: venous thromboembolism; BMI: body mass index.
* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and
reconstructive surgery. See text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy
and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines.
Chest 2012; 141:e227S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.
Dietary sources of iron
Food Approximate measure Iron (mg)
High-iron sources
Cereals, fortified 1 serving 4.5 to 17.8
Cream of Wheat (quick or 1/2 cup 7.8

instant)*
Kidney, beef ¶ 2 oz (60 g) 5.3
Liver, beef ¶ 2 oz (60 g) 5.8
Liver, calf ¶ 2 oz (60 g) 9
Liver, chicken ¶ 2 oz (60 g) 6
Liverwurst ¶ 2 oz (60 g) 3.6
Nuts Δ 1 cup 5 to 7
Prune juice 1/2 cup 5.1
Seeds, sunflower Δ 3 1/2 oz (100 g) 7.1
Moderate-iron sources
Almonds, dried, unblanched 1/2 cup 3
Dried beans and peas
Baked beans, no pork 1/4 cup 1.5
Blackeye peas, cooked 1/4 cup 0.8
Chick peas, dry 1/4 cup 3.5
Great northern beans, 1/4 cup 1.3

cooked
Green peas, cooked 1/4 cup 1.4
Lentils, dry 1/4 cup 3.4
Lima beans, cooked 1/4 cup 1.3
Navy beans, cooked 1/4 cup 1.3
Red beans, dry 1/4 cup 3.5
Soybeans, cooked 1/4 cup 1.4
White beans, dry 1/4 cup 3.9
Beef, cooked ◊ 2 oz (60 g) 2 to 3
Ham, cooked 2 oz (60 g) 1.3
Lamb, cooked 2 oz (60 g) 1.9
Peaches, dried 1/4 cup 2.4
Peanuts, roasted without 3 1/2 oz (100 g) 3.2

skins
Pork, cooked § 2 oz (60 g) 2 to 3
Prunes, dried 2 large 1.1
Raisins Δ 5/8 cup 3.5
Scallops 2 oz (60 g) 1.6
Spinach (cooked) 1/2 cup 3.2
Spinach (raw) 1 cup 0.9
Turkey, cooked 2 oz (60 g) 1.7
Approximate iron content of popular prepared foods
Hamburger
Small 1 3
Large 1 5.2
Spaghetti with meatballs 1 cup 3.3
Frankfurter and beans 1 cup 4.8
Pork and beans 1 cup 5.9
Chile con carne 1 cup 3.6
Beef burrito or tostado 1 medium 3.4 to 4.6
Cheese pizza 2 slices 3
Cheese pizza with beef 2 slices 4.8
White bread 1 piece 0.7
* Or other fortified cereals that contain 10 mg of iron per ounce or 100% recommended dietary
allowance per serving.
¶ Because organ meats are generally high in cholesterol, these iron-rich foods should be eaten in
moderation.
Δ Raisins, nuts, and seeds are not generally recommended for children under age 3, because of risk
of choking.
◊ Depending on cut, the greatest amounts of iron are generally found in the chuck, flank, and
bottom round cuts of beef.
§ Depending on cut, the greatest amounts of iron are generally found in the loin, sirloin, tenderloin,
and picnic shoulder cuts of pork.
Data from: Walker WA, Watkins JB (Eds), Nutrition in Pediatrics, 2nd ed, BC Decker, Inc, London 1997.
Vaccinations for adults (age >19 years) with impaired splenic function and
adults undergoing splenectomy in the United States*
Vaccine Primary series Revaccination (booster)
Pneumococcal vaccine 1 dose of PCV20 or PCV15. If Not applicable

PCV20 alone or PCV15 PCV15 is used, 1 dose of PPSV23
plus PPSV23 ≥8 weeks later
Haemophilus influenzae type b 1 dose ¶ Not applicable

vaccine
Hib
Meningococcal serotype 2 doses at least 8 weeks apart Δ Every 5 years

ACWY vaccine
MenACWY (Menactra,
Menveo, or MenQuadfi)
Meningococcal serotype B 2 doses of MenB-4C at least 1 1 year after completing the

MenB-FHbp (Trumenba) month apart or 3 doses of primary series and every 2 to 3
or MenB-4C (Bexsero) MenB-FHbp at 0, 1 to 2, and 6 years thereafter
months ◊
Seasonal influenza virus 1 dose annually at the start of Repeat annually at start of
influenza season influenza season
This table should be used in conjunction with the UpToDate topic on prevention of sepsis in patients
with impaired splenic function. In addition to the vaccines above, patients with impaired splenic
function should also receive all routinely recommended age-appropriate vaccines (including
coronavirus disease 2019 [COVID-19] vaccination). For patients undergoing elective splenectomy,
vaccinations should be given at least 14 days prior to the procedure and ideally 10 to 12 weeks prior.
For patients undergoing emergency splenectomy, vaccine series should be started 14 days after
splenectomy. For patients with nonsurgical asplenia or hyposplenism, vaccinations should be given
as soon as impaired splenic function is recognized.
PCV20: 20-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate

vaccine; 23-valent pneumococcal polysaccharides: PPSV23.
* Available vaccine formulations and recommendations may differ outside of the United States.
¶ Hib vaccination is recommended for all adults who have not been previously vaccinated or if
vaccination status is unknown.
Δ If primary series already received, continue revaccinating every 5 years.
◊ If not already received.
Contributor Disclosures
Ellen F Manzullo, MD, FACP No relevant financial relationship(s) with ineligible companies to
disclose. Sunil K Sahai, MD, FAAP, FACP No relevant financial relationship(s) with ineligible companies to
disclose. Harrison G Weed, MS, MD, FACP No relevant financial relationship(s) with ineligible companies
to disclose. Reed E Drews, MD No relevant financial relationship(s) with ineligible companies to
disclose. Sadhna R Vora, MD No relevant financial relationship(s) with ineligible companies to disclose.
El grupo editorial revisa las divulgaciones de los contribuyentes en busca de conflictos de intereses.
Cuando se encuentran, estos se abordan mediante la investigación a través de un proceso de revisión de
múltiples niveles y mediante los requisitos para que se proporcionen referencias para respaldar el
contenido. Se requiere que todos los autores tengan contenido referenciado de manera adecuada y debe
cumplir con los estándares de evidencia de UpToDate.
Política de conflicto de intereses

Evaluación y Manejo Preoperatorio de Pacientes Con Cáncer - UpToDate

Cargado por

Información del documento

Descripción original:

Derechos de autor

Formatos disponibles

Compartir este documento

Compartir o incrustar documentos

Opciones para compartir

¿Le pareció útil este documento?

¿Este contenido es inapropiado?

Copyright:

Formatos disponibles

Evaluación y Manejo Preoperatorio de Pacientes Con Cáncer - UpToDate

Cargado por

Copyright:

Formatos disponibles

14/3/23, 23:02 Evaluación y manejo preoperatorio de pacientes con cáncer - UpToDate

Reimpresión oficial de UpToDate ®

Evaluación preoperatoria y manejo de pacientes con

El momento y el propósito de la cirugía del cáncer pueden afectar la evaluación perioperatoria.

Además de manejar las condiciones médicas coexistentes, el internista también puede

The indiscriminate use of enteral or parenteral nutrition is not indicated in well-nourished

On the other hand, nutrition optimization is an important component of enhanced recovery

● Seven to 10 days of preoperative parenteral nutritional support for severely malnourished

NSAIDs may be contraindicated in patients with thrombocytopenia from cancer or its

An algorithmic approach to assessment of cardiac risk prior to noncardiac surgery is provided

Echocardiography should be performed if physical examination reveals findings consistent with

Cardiac toxicity from chemotherapy — Certain chemotherapeutic agents, particularly

Electrocardiographic abnormalities such as sinus tachycardia, premature atrial or ventricular

In addition, checkpoint inhibitor immunotherapy may be associated with immune-mediated

Medication management — Recommendations for management of medications for

CARDIOPULMONARY MASS EFFECTS

● Fiberoptic intubation while awake

Treatment-related pulmonary toxicity — Both chemotherapy and radiation therapy can

Bleomycin is associated with significant pulmonary toxicity in up to 10 percent of patients, and

In addition, patients undergoing checkpoint inhibitor immunotherapy may have an immune-

ENDOCRINE AND ELECTROLYTE STATUS

Glucocorticoids — Many chemotherapeutic regimens include glucocorticoids, either as a

Standard recommendations for perioperative management of diabetes are available elsewhere.

Hyponatremia — Preoperative hyponatremia can occur in cancer patients, and may be

Preoperative hyponatremia may be associated with increased risk for postoperative

Hypercalcemia — Hypercalcemia is a common complication of cancer, occurring in up to 15

Adrenal insufficiency — Adrenal insufficiency can occur in cancer patients as a result of

● HPA axis suppression should be assumed to be present in patients taking prednisone at a

● Patients on intermediate doses of glucocorticoids should undergo testing, although many

Adrenal insufficiency should be considered in postoperative patients with hypotension that is

● In one study, 41 percent of patients with Hodgkin lymphoma who received 15 to 40 Gy to

● A systemic review of radiation-induced hypothyroidism in head and neck cancer patients

Carcinoid crisis — Carcinoid crisis is a life-threatening form of carcinoid syndrome that

Pheochromocytoma/paraganglioma surgery — Pheochromocytomas are rare

Hypercoagulability — A hypercoagulable state is common in patients with cancer, particularly

Hypercoagulability (leading to arterial [myocardial infarction and stroke] as well as venous

Anemia — Anemia is common in cancer patients, and it is frequently undertreated. Anemia is

Neutropenia and lymphopenia — Patients who are myelosuppressed as a result of

Whenever possible, nonemergency surgery should be postponed in neutropenic patients.

Thrombocytopenia — Thrombocytopenia can occur in cancer patients either as a result of the

Paraneoplastic syndromes — Paraneoplastic syndromes that affect neuromuscular function

with anesthetic agents can exacerbate neuromuscular dysfunction, leading to respiratory

OTHER EFFECTS OF CHEMOTHERAPY

Hepatotoxicity — Several chemotherapeutic agents are potentially hepatotoxic. Although most

Reactivation of viral hepatitis (particularly hepatitis B virus [HBV]) is a potential complication of

Nephrotoxicity — Several chemotherapeutic agents are potentially nephrotoxic, particularly

Wound healing — Impaired wound healing is a well-described complication of certain

IMMUNIZATIONS PRIOR TO SPLENECTOMY

impaired splenic function" and "Elective (diagnostic or therapeutic) splenectomy", section on

• Patients with symptomatic pericardial effusions, cardiac tamponade, or constrictive

assessed preoperatively. (See 'Cardiopulmonary mass effects' above.)

● Endocrine and electrolyte issues

• Measure serum thyroid stimulating hormone and free T4 concentrations in patients

• Preoperative pharmacologic preparation is indicated for all patients with

• When feasible, postpone surgery to allow recovery from chemotherapy-induced

• Reactivation of viral hepatitis (particularly hepatitis B virus [HBV]) is a potential

• Impaired wound healing is a well-described complication of certain chemotherapy

• For patients in whom concomitant splenectomy is anticipated (eg, resection of a distal

Use of UpToDate is subject to the Terms of Use.

Multiple-hit hypothesis for cancer deconditioning

Multiple-hit hypothesis for cancer deconditioning.

Graphic 113780 Version 6.0

Approximate dose conversions for commonly used opioids (refer to