EAU 2018: Optimizing Anesthesia in the Frail Patient with Bladder Cancer: What the Urologist Needs to Know

Copenhagen, Denmark (UroToday.com) Dr. Wuethrich from Switzerland succinctly summarized anesthesia concerns for frail, elderly patients with bladder cancer. Dr. Wuethrich commenced by noting that frailty is the outcome of two combined effects: the aging process and superimposed injuries (chronic disease, psychological and social stress). From a geriatrician perspective, patients with frailty should be treated if they are (i) depressed, (ii) require testosterone replacement therapy, (iii) have hypothyroidism, and (iv) require vascular disease treatment. Exercise is a cornerstone of the management of frailty at least three times per week, and elderly people who are eating poorly should be encouraged to increase their food intact including vitamins. 

Prehabilitation is important for preoperative care and includes optimizing nutrition as soon as possible and no later than 2-4 weeks preoperatively. This helps to reduce sarcopenia and improve muscle strength. Daily requirements should be:

  • Whey protein: 1.2 g/kgBW 
  • Carbohydrates: 275 grams
  • Protein drinks: 40 grams
  • Vitamin D: 1000 IU
  • Calcium: 960 mg
It is important to optimize nutrition as soon as possible, which includes oral immune-enhancing nutritional supplement > 5 days preoperatively and carbohydrate loading <24 hour preoperatively. Second it is important to bring the patient hydrated to the OR, which means there is no role for enteral bowel preparation and patients should only be without solid food for 6 hours and without clear liquids for 2 hours. 

Preoperative anemia is also an important consideration for prehabilitation prior to a radical cystectomy in frail elderly patients with a prevalence of >50% and iron deficiency in >45%. Dr. Wuethrich recommends use of a new IV iron formulation (single dose 1000 mg), which is cost effect and safe with rapid and more complete hematologic response. Second rhuErythropoietin is recommended for Hgb 10-13 g/dL (for orthopedic surgery), but is off-label for gastrointestinal cancer. Co-administration of iron and rhuErythropoietin enhances response. Improving physical fitness is also important, specifically breathing training and smoking cessation. Preoperative physiotherapy with education and breathing training reduces the pulmonary complications by 50% (ie. pneumonia) and inspiratory muscle training (breathing against resistance) reduces pulmonary complications by 36% (atelectasis). Patients that stop smoking >4 weeks prior to surgery have reduced complication rates and <4 weeks has no impact on complications but reduces carboxyhemoglobin concentration in the blood. 

Frail patients should have fast and meticulous surgery and require impeccable intraoperative care. It is crucial to avoid re-operations as this leads to a 2-14 fold increased risk of mortality Specific anesthetic techniques include (i) aggressive post-operative nausea/vomiting prevention using ondansetron or dexamethasone, (ii) normothermia/normoglycemia, which reduces infection rates, (iii) normotonia, for example being within 10% of the patient’s resting systolic blood pressure with vasopressors, and (iv) fluid management in order to avoid fluid and salt overload, which reduces risk of organ dysfunction and risk of complications. Administration of a large amount of IV fluid may cause iatrogenic hemodilution and paradoxical decrease DO2. The baseline rate of maintenance fluid should be <1-2 mL/kgBW/hr and should not be 0.9% normal saline as this can lead to acidosis and acute kidney injury.

Frail patients are at high risk of postoperative delirium and in-hospital mortality is subsequently high (19%). In fact, the number of days of delirium is significantly associated with mortality up to 1-year after admission. Several ways to decrease post-operative delirium include (i) shorter operation times, (ii) low-dose dexmedetomidine, avoiding too deep of anesthesia, (iii) avoid additional psychoactive substances (benzodiazepines, opioids), and post-operative geriatric rehabilitation. 

Dr.  Wuethrich concluded with several important messages: (i) preoperatively, it is important to optimize physical fitness and nutritional status including hydration; (ii) intraoperatively/post-operatively, patients should be normotonic, have optimization of fluid administration, offered regional anesthesia with multimodal opioid free analgesia, a trigger of blood transfusion of 9 g/dL, succinct operations, and a postoperative geriatric unit. 

Presented by: Patrick Y. Wuethrich, University Hospital, Berne, Switzerland

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark