Journal of Anaesthesia & Critical Care Review Article

Anesthetic Considerations in Ovarian Cancer Patients: A

Comprehensive review
*
Uma Hariharan , Shagun Bhatia Shah
Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
*
Corresponding Author: Dr Uma Hariharan
BH 41, East Shalimar Bagh
Delhi 110088, India.
Received Date: December 30, 2015; Accepted Date: January 18, 2016; Published Date: January 29, 2016
Citation: Hariharan U, Shah SB (2016) Anesthetic Considerations in Ovarian Cancer Patients: A
Comprehensive review. Jol Aneth Criti Cre 2:10460.
Copyright: © 2015 Hariharan U, et al. This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.

Abstract
Ovarian carcinoma is one of the leading gynaecological cancers affecting an increasing number of
women world-wide. The stage of presentation decides the mode of treatment: chemotherapy,
cytoreductive surgery or a combination of both. Maintaining hemodynamic stability during massive fluid
shifts, extensive monitoring, pre induction epidural catheter placement, prevention of hypothermia during
cytoreductive surgery and hyperthermia during intraperitoneal chemotherapy phase, correction of
metabolic or electrolyte derangements and adequate postoperative pain relief are the main perioperative
goals. Anesthetic implications of cytoreductive surgery, chemotherapy (in particular heated intraperitoneal
chemotherapy) and chemoport insertions are also reviewed in this article.

Keywords: Ovarian carcinoma; Anesthetic developed for these patients in order to improve

considerations; Cytoreductive surgery; patient safety and quality of anesthetic care.

Chemotherapy; Cancer staging; HIPEC; Debulking. Anesthesiologists should also be aware of the
various stages of ovarian carcinoma and their
Introduction purported line of treatment, so as to individualize
their anesthetic management. There is also evidence
Ovarian cancer is the fifth most common
of association between cancer recurrence and the
cancer in females across Europe, with a steadily
type of anesthesia chosen [2]. In addition to the
increasing incidence in women of child bearing age.
perioperative considerations for cytoreductive
Since surgery forms the backbone of management
surgery, anesthesiologists may also be involved in
of ovarian carcinoma, anesthesiologists would more
the care of patients undergoing various types of
frequently encounter cases of ovarian cancer in the
chemotherapy as part of the ovarian cancer
operation theatre and outside [1]. Special protocols
management.
for the overall perioperative care should be

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Current FIGO classification for ovarian + Retroperitoneal lymph nodes only

carcinoma III A1 III A1 (i) Metastasis </= 10mm
The International Federation of III A 1 (ii) Metastasis > 10mm
Gynecologists and Obstetricians in 2014 revised the Microscopic, extrapelvic (above the
staging classification of ovarian cancers, which has III A2 brim) peritoneal involvement ± Positive
important treatment implications [3]. The following Retroperitoneal Lymph Nodes (RPLN)
table highlights the current staging for carcinoma Macroscopic, extrapelvic, peritoneal
ovary
metastasis <= 2cm ± positive RPLN,
III B
Stage Includes extension to capsule of
Description
liver/spleen.
Tumor limited to 1 ovary, capsule intact,
IA Macroscopic, extrapelvic, peritoneal
no tumor on surface, negative washings
metastasis > 2cm ± positive RPLN,
Tumor involves both ovaries otherwise like III C
IB includes extension to capsule of
IA
liver/spleen.
I C1 Surgical spill
Stage III: Tumor involves 1 or both ovaries with
Capsule rupture before surgery or tumor
IC 2 cytologically or histologically confirmed spread to the
on ovarian surface
peritoneum outside the pelvis and/or metastasis to
Malignant cells in the ascites or peritoneal
IC 3 the retroperitoneal lymph nodes.
washings.

Stage 1: Tumor confined to ovaries Stage Description

IV A Pleural effusion with positive cytology
Stage Description
Hepatic and/or splenic parenchymal
Extension and/or implant on uterus and/or metastasis, metastasis to extra-
II A
Fallopian tubes IV B abdominal organs (including inguinal
Extension to other pelvic intraperitoneal lymph nodes and lymph nodes outside
II B
tissues of the abdominal cavity)

Stage II: Tumor involves 1 or both ovaries with Stage IV: Distant metastasis excluding peritoneal
pelvic extension (below the pelvic brim) or primary metastasis.
peritoneal cancer The type of ovarian tumor also influences the line of
management and prognosis. Cancerous ovarian
Stage Description
lesions arise from four important cell types:
Positive retroperitoneal lymph nodes
1. Surface Epithelium (Carcinomas): They are
III A and/or microscopic metastasis beyond
the most common and the most sinister type.
the pelvis
These may present at an advanced stage for

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treatment and pose various management debulking is defined as an operation performed after
challenges. a short course of induction chemotherapy, usually 2
2. Germ Cell Tumors (Teratoma, or 3 cycles. In women of reproductive age with low
Dysgerminomas and Endodermal sinus grade cancer, there is also a possibility of retention
tumor): Most of them are benign and occur of the contralateral ovary or the option of ovum
in younger women, with excellent prognosis. preservation for future use. Fertility issues have to
3. Stromal tumors (Granulosa-Theca cell be discussed with the patient preoperatively [7].
tumors and Sertoli-Leydig cell tumors): They Chemotherapy can be given either before or after
are rare, hormone-secreting tumors arising the definitive surgery. With the advent of HIPEC,
from the ovarian connective tissue. hyperthermic chemotherapy can be delivered directly
4. Primary Peritoneal Carcinoma: They are to the cancer cells of the peritoneal cavity after the
similar to ovarian epithelial tumors and arise cytoreductive surgery [8]. This has significantly
from cells lining the peritoneum (eg. reduced cancer recurrence, but at the same time has
Psuedomyxoma peritonei) and can be raised several patient safety concerns. Radiotherapy
associated with massive or recurrent ascites. may be given for metastasis and is rarely given in
ovarian cancer patients. Advanced ovarian cancer
Treatment modalities for ovarian cancer
has a poor prognosis. Anesthesiologists may be

Management of ovarian cancer depends on involved not only in cytoreductive surgery and

the stage at presentation with a recent trend towards HIPEC, but also in chronic pain management as well

curative rather than palliative approach [4]. Surgical as palliative care of these patients. Primary

treatment forms the mainstay and includes staging debulking surgery followed by platinum based

laparotomy, bilateral salpingo-opherectomy, chemotherapy forms the mainstay of advanced

hysterectomy, exploration for metastatic deposits, ovarian cancer treatment. Recently, Neoadjuvant

extensive biopsies, peritoneal fluid sampling, chemotherapy to reduce tumor bulk preoperatively

lymphadenectomy, peritonectomy, omentectomy and followed by interval debulking surgery has been

surgical debulking of the tumor. In some developed in extensive stage IIIc or IV tumors [9].

circumstances, splenectomy, bowel resection- The postoperative complications and mortality rates

anastomosis, appendicectomy, cholecystectomy and were found to be lower after interval debulking. An

partial liver resections may also be required for important concern here is the inability to obtain the

adequate cytoreduction [5]. The aim is to remove as goal of no residual tumor due to chemotherapy-

much tumor as possible. Recent surgical advances induced fibrosis. It must be remembered that very

in the form of use of harmonic cautery, cryoablation aggressive surgery in advanced ovarian cancer can

and robot-assisted radical surgery have improved result in unnecessary morbidity and mortality without

patient outcomes. Optimal debulking surgery is improving overall survival.

defined as no residual tumor load [6]. Interval

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Preoperative Considerations for Ovarian diabetes mellitus, hypertension, coronary artery

Laparotomy disease, reactive airway disease and thyroid function
The main preoperative concerns include the derangements have to be adequately optimized.
anesthetic implications of chemotherapeutic agents, Ovarian cancer patients have an increased
evaluation of organ system affliction by the propensity to develop Venous Thromboembolism
malignancy/metastasis, problems due to ascites, (VTE). The Trousseau sign of malignancy or the
DVT (Deep Vein Thrombosis) prophylaxis and Trousseau`s syndrome involves recurrent
discussions regarding options of perioperative pain thrombophlebitis appearing in different locations over
management [10]. Pre-anesthetic evaluation must be time [12]. They occur due to the hypercoagulable
extensive and thorough. All routine investigations state associated with malignancies of the pancreas,
including complete hemogram, renal function tests, lung, stomach and ovary. Hence, mechanical
liver function tests, serum electrolytes and thromboprophylaxis and early ambulation must be
coagulation profile need to be done. Patient may utilized in all cases. Patients should also be
have derangement in liver functions, especially low counseled regarding the benefits of epidural
protein and high enzyme levels, due to large ascites analgesia during the pre-anesthetic visit
or metastatic deposits. Presence of ascites may
Intra-operative Anesthetic Management
cause reduction in functional residual capacity and
pushing up of the diaphragm [11]. Pulmonary Prioritization of anesthetic considerations
function derangement may also be due to concurrent must be done to reduce patient morbidity and
pleural effusion. If patient is on diuretics mortality. Intra-operative care must focus on
preoperatively, then there may be electrolyte managing the hemodynamics during fluid/blood loss;
derangements. Hypokalemia has serious maintaining oxygenation, normothermia and
implications with the intra-operative use of normocarbia; supplementing analgesia with epidural
neuromuscular blocking agents. In patients who had drugs; and preventing perioperative
undertaken neo-adjuvant chemotherapy, the toxic metabolic/electrolyte derangements. Preinduction
effects of the chemotherapeutic drugs must also be thoracic epidural catheter insertion under local
considered. Apart from immunosuppression, these anesthesia is encouraged to decrease the stress of
drugs can cause toxicity of various organ systems anesthesia and surgery [13]. Two large-bore
including pulmonary, cardiac, kidney and liver. In intravenous cannulas should be secured to take care
cardiac evaluation, an ECG (Electrocardiogram) and of the blood and fluid loss replacement. Massive fluid
a baseline echocardiography should be done to rule shifts can occur in patients with large ascites. Ascitic
out cardiomyopathy, pericardial involvement and fluid drainage on opening the abdomen must be
ventricular function derangement. Preoperative done slowly to avoid sudden hemodynamic
tapping of ascitic fluid may be beneficial in relieving decompensation. Blood loss can be extensive due to
respiratory distress. Co-existing diseases like continuous oozing and the nature of radical surgery.

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Invasive monitoring lines need to be secured for warmers can be used during large volume
guiding intravascular volume management. intravenous infusions. An indigenous low-cost blood
Preinduction arterial and central venous catheter and fluid warmer made from gloves can be used if
insertion under ultrasound guidance can be done. commercially available equipment is not available
Rapid sequence induction with cricoid pressure [18]. Hourly urine output monitoring is mandatory to
(after adequate preoxygenation and aspiration ensure adequate renal perfusion as it accurately
prophylaxis) is usually recommended in patients with reflects the status of intravascular volume. In these
massive ascites or with metastatic tumor causing surgeries involving massive fluid shifts, a urine
intestinal or gastric obstruction. In patients in pre- output of at least 0.5 - 1ml/Kg/hour should be
existing hepatic or renal impairment, Atracurium or maintained. Other monitors of intravascular volume
cis-Atracurium can be used as the neuromuscular status should be utilized to guide us regarding fluid
blocking agent, usually as a continuous infusion infusions and the need for diuretic use. For
under neuromuscular monitoring [14]. Nitrous oxide excessive protein loss, albumin infusions (salt-poor
is usually avoided to decrease the risk of air 20% albumin solution) can be infused intra-
embolism and reduce bowel distension. operatively. Some patients may require vasopressor
Endotracheal intubation with controlled mechanical support to maintain an adequate mean arterial blood
ventilation is preferred, with caution to prevent pressure in the perioperative period. Blood loss
hypotension on induction [15]. The Fraction of replacement should be done according to standard
Inspired Oxygen (FiO2) has to be limited in patients protocols after calculation of MABL (maximal
who have undergone chemotherapy with Bleomycin allowable blood loss) [19]. Estimation of blood loss
and its analogues [16]. Inhalational agents with O 2 + has to be meticulous as blood may be mixed with
Air mixture can be administered along with ascitic and serous fluid. In patients coming for
continuous Propofol infusion under intraoperative interval debulking after neoadjuvant chemotherapy
BIS (Bi-Spectral Index) monitoring. Two important or re-do surgery after primary debulking, the amount
considerations in patients with ascites and advanced of blood loss may be greater in view of fibrosis. In
ovarian cancer are the prevention of hypothermia cases with excessive blood loss due to extensive
and maintenance of adequate urine output. Ensuring resections for optimal debulking, all possible
normothermia may be difficult as there is continuous complications of massive blood transfusion must be
oozing from the large, exposed peritoneal surfaces. kept in mind. Intravenous calcium gluconate may be
Active warming measures should be adopted in the infused to prevent hypercitratemia after 4 or 5 units
form of warm intravenous fluids and cleaning of blood transfusion. Metabolic derangements are
solutions, raising the ambient temperature of the common during extensive ovarian laparotomies.
operating room, patient warming blankets, using Arterial blood gas analysis may be done to assess
warm fluids for abdominal wash and covering all the level of base deficit, lactic acidosis, oxygenation
exposed areas of the body [17]. Electric fluid and anion gap. Electrolyte imbalances necessitating

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correction may occur in the perioperative period due parameters, development of complications, choice
to fluid shifts, diuretic use and blood or blood product and dose of anesthetic and analgesic drugs. Both
transfusion. Particular attention should be paid invasive and non-invasive monitoring devices can be
towards potassium balance, as both hypo- and utilized for improving patient outcome. Apart from
hyperkalemia are common [20]. There may be routine standard ASA monitors (SpO2, ECG, NIBP,
vitiation of glycemic control in diabetic patients Temperature and ETCO2), neuromuscular monitor,
during these extensive surgeries. Titrated BIS, airway and cuff pressure gauges, urine output
intravenous insulin infusion, piggy-backed with and ventilatory parameter monitoring in
dextrose infusion and hourly blood sugar monitoring recommended for such extensive surgeries. Newer
can be extremely beneficial. Particular attention must measures of tissue perfusion and intravascular
be paid to ensuring complete asepsis during all volumes like the perfusion index, pleth variability
procedures as these patients are index, caval index and co-oximetry have
immunosuppressed [21]. Special precautions should revolutionized the field of perioperative monitoring in
be taken while caring for invasive lines and epidural high-risk patient population [22]. A recent addition to
catheters. Epidural analgesia must be offered to all the existing armamentarium of monitors is the use of
patients, provided there is no pre-existing intraoperative lung scanning with ultrasound. Not
coagulopathy. Not only does it reduces anesthetic only does it provide information regarding lung zone
requirements and stress of surgery, but also reduces status (atelectasis, pleural effusion and
doses of systemic opioids and delays cancer consolidation), but also about extravascular lung
recurrence. Most of these patients can be extubated water, pneumothorax and pleural conditions. In
in the operating room post surgery, provided they patients with concurrent cardiac conditions, there is
are hemodynamically stable with good respiratory also recent evidence of using TEE
efforts. If a pleural rent occurs in the course of (Transesophageal Echocardiography) for measuring
optimal debulking, then a chest tube should be various cardiac parameters in non-cardiac surgeries
inserted before abdomen closure and extubation. All [23]. TEE probe can be inserted atraumatically in
of them need to be observed in an onco-surgical high-risk cases into the oseophagus after anesthesia
intensive care unit with complete monitoring. DVT induction and endotracheal intubation. They provide
prophylaxis, both mechanical and pharmacological real-time views of various cardiac chambers and
as well as PONV (Postoperative Nausea Vomiting) giving vital information about the ventricular filling
prophylaxis needs to be given to all these patients. pressures, contractility, presence of thrombus and
intravascular volume status. With the advancement
Monitoring
in biotechnology and the advent of novel monitors

Monitoring for ovarian cancer laparotomy like Vigileo TM and FloTrac TM, the use of invasive

must be extensive in order to guide us regarding monitors like the PA (pulmonary artery) catheters

fluid therapy, replacement of blood loss, ventilatory has drastically reduced [24]. Securing of arterial line

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for invasive blood pressure and arterial blood gas fluid shifts, blood loss and dyselectrolytemias.
analysis is helpful in beat-to-beat monitoring, pulse Thermal stress causes a hyperdynamic circulatory
contour analysis and detecting perioperative acid- state which warrants meticulous volume
base disturbances. Serum lactate levels give a fair management and hemodynamic monitoring [30].
estimate of the adequacy of tissue perfusion and in Blood and blood product availability must be ensured
assessing metabolic acidosis [25]. In patients in the blood bank prior to induction. Coagulopathy is
undergoing HIPEC after cytoreductive surgery, TEG the result of dilution of platelets and coagulation
(Thromboelastography) can be used to monitor the factors by large volume fluid infusions. The other
intraoperative coagulation status [26]. Nevertheless, important anesthetic considerations include protein
one must remember that an astute and a vigilant loss, increased intra-abdominal pressure, decreased
anesthesiologist is the best monitor. oxygen delivery to the microcirculation, rise in
metabolic rate and extremes of body temperature.
Anesthetic considerations for HIPEC
Heat stress leads to increase in heart rate, cardiac

HIPEC stands for hyperthermic output and end tidal carbon-dioxide, resulting in fall

intraperitoneal chemotherapy. It was first used in in SVR (Systemic Vascular Resistance) and

1980 by Spratt et al for the treatment of peripheral vasodilatation. It is prudent to keep the

pseudomyxoma peritonei [27]. In the recent times, core temperature at 35 degrees Celsius before the

HIPEC when combined with cytoreductive surgery start of hyperthermic chemotherapy so that the core

has been proved to be better than the use of temperature is maintained below 38 degrees Celsius

intravenous chemotherapy. There have been several during the procedure [31]. Anesthesiologists must

case reports and review articles citing the utility and remember to switch off patient and fluid warmers

anesthetic considerations of HIPEC [28]. The before the start of HIPEC, to prevent dangerous

peritoneal cavity is filled with high-dose heated hyperthermia. The ultimate goal is to maintain

chemotherapeutic solution resulting in a large normothermia, as both hypo-and hyperthermia are

exposure of tumor cells to high-dose chemotherapy. deleterious to the patient. The anesthesiologist must

This has been shown to increase the drug’s ensure adequate intravenous fluid hydration as well

therapeutic effect due to selective hyperthermia- as good hourly urine output (1-2ml/Kg/hour). Further,

induced cytotoxicity of malignant cells. Anesthetic heated chemotherapeutic agents like Cisplatin can

implications are primarily due to disturbances in cause nephrotoxicity. The introduction of HIPEC has

coagulation, hemodynamics, respiratory gas improved both the 5-year survival rate and the

exchange and thermoregulation [29]. The pre- median survival rate in ovarian cancer patients [32].

anesthetic assessment must focus on co-morbidities Anesthesiologists must be geared up to face the

which may be exacerbated by the large fluid shifts newer challenges posed by these advancements in

during the heated chemotherapeutic phase. It is a oncologic treatments.

complex, long-duration surgery with resultant large

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Postoperative Care vigilance is the key to improving post-surgical patient

survival.
Meticulous postoperative care is the
cornerstone of successful anesthetic management of Pain Management
ovarian cancer patients. Monitoring of vital
Adequate perioperative pain management is
parameters, including arterial and central venous
the cornerstone of successful cytoreductive surgery
pressures should be continued. All patients should
program for ovarian cancer patients. Epidural
be kept adequately warm. Pain relief should be
analgesia is required, considering the length of
instituted through an epidural infusion (continuous or
incision and amount of retraction done during
patient controlled analgesia) of local anesthetics
surgery. A combination of Ropivacaine (0.25%) and
combined with an opioid. Adequate analgesia
Sufentanil (10-15 micrograms) through continuous
ensures that the patient generates sufficient vital
epidural infusion can be given, where available.
capacity, thus preventing postoperative atelectasis
Bupivacaine (0.25 – 0.125%) with Fentanyl (20-30
33. Hourly urine output charting and VAS (Visual
mcg/hour) can also be infused. Thoracic Epidural
Analogue Score) assessment should be done.
Analgesia (TEA) is beneficial in decreasing oxygen
Insulin and dextrose infusions must be continued in
consumption and improving lung function, apart from
the postoperative period in diabetic cancer patients
reducing the overall stress response. Epidural
for better would healing and prevention of ketosis.
analgesia is also known to reduce cancer recurrence
DVT prophylaxis should be instituted in the form of
in these patients. In addition, epidural analgesia is
calf pumps, compression stockings and
associated with decreased perioperative need of
subcutaneous LMWH (Low Molecular Weight
opioids and postoperative ventilation. Patient
Heparin). Patients undergoing extensive resections
Controlled Analgesia (PCA) is the current dictum, as
or massive fluid shifts with co-existing organ system
not only does it gives a basal dose of the drug, but
derangements may require a short period of
also gives a sense of control over the pain for the
postoperative ventilation to take care of the
patient by giving additional bolus doses as desired
interstitial edema and hemodynamic instability.
[35]. Both PCEA (Patient Controlled Epidural
Respiratory parameters, ABG (Arterial Blood Gas
Analgesia) and PCIA (Patient Controlled Intravenous
Analysis) analysis and postoperative lung ultrasound
Analgesia) can be utilized as required. PCIA can be
scanning can guide us regarding extubation in the
used in patients with coagulopathies or on
onco-surgical intensive care unit [34]. Ovarian
anticoagulants. For patients in whom epidural
cancer patients with co-existing cardio-respiratory
catheter is contraindicated, ultrasound guided TAP
problems have a high risk of developing
(Transversus Abdominus Plane) block can be given
postoperative complications like myocardial
for postoperative analgesia. Care has to be taken in
ischemia, arrhythmias, respiratory failure,
patients undergoing HIPEC, as they are prone to
pneumothorax and pulmonary edema. Eternal
develop derangements in coagulation due to large

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fluid shifts, protein loss, hyperthermic chemotherapy long-term venous access. Chemo-port insertion
and fall in antithrombin-III levels. Multimodal usually is done under local anesthesia and
analgesia is effective for pain management in these Monitored Anesthesia Care (MAC) [39]. The main
patients and helps in earlier postoperative recovery. entry sites include right internal jugular vein (most
In addition to epidural analgesia, NSAIDs common and the most favored), followed by right
(contraindicated if there is renal function subclavian, left internal jugular and the inferior vena
derangement), intravenous Paracetamol and low cava. The success rate is improved with concurrent
dose opioids can be supplemented. In a recent image guidance by ultrasound and fluoroscopy.
study, it was found that intraoperative neuraxial Anesthesiologists need to be aware of the possible
anesthesia and not postoperative neuraxial complications of chemo-port insertion, in order to be
analgesia is associated with increased relapse free ready to successfully manage the eventualities. The
survival after primary cytoreductive surgery for major immediate complications include arterial
ovarian cancer [36]. Intraoperative epidural puncture, pneumothorax, air embolism, hematoma
anesthesia resulted in increased time to tumor formation, arrythmias and cardiac arrest. The most
recurrence after ovarian cancer surgery, which may common early complications include catheter
be due to preservation of the immune system blockade, infection, catheter malposition, venous
function. In another study done on advanced ovarian thrombosis, catheter dislodgement or leak.
cancer patients in Chilean population, no benefit in Coagulopathy and sepsis are the main
overall survival or time to recurrence was found contraindications to chemo-port insertions, apart
among FIGO stage IIIC and IV of carcinoma ovary, from patient refusal. Anesthesiologists need to be
after the use of epidural analgesia during and after careful regarding the dose of sedatives and local
tumor de-bulking [37]. Patients with recurrent or anesthetics administered during the procedure to
metastatic ovarian cancer may experience chronic avoid over-sedation and local anesthetic toxicity.
pelvic pain or low backaches or abdominal Proper ASA fasting guidelines and monitoring
discomfort. Ultrasound or fluoroscopy-guided chronic standards must be strictly followed during the entire
pain blocks can be given in the operation theatre by procedure. A major advancement in this regard is
interventional pain physicians [38]. These include the development of Intraperitoneal Chemoport (IPC)
pudendal nerve block, hypogastric plexus block, insertion in stage 3c and 4 ovarian cancer patients
facet blocks, ganglion impar block and intrathecal [40]. It is considered better than intravenous
pumps. chemotherapy as it can be used for both
intraoperative and post-operative chemotherapy. It
Chemotherapy and Radiotherapy
must be realized that HIPEC can only be used

As chemotherapy for ovarian cancer (both intraoperatively as compared to IPC insertion,

neo-adjuvant and adjuvant) is given over several through which upto 6 doses of chemotherapy can be

cycles, it is preferable to insert a chemo-port for administered postoperatively. IPC insertion requires

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the administration of general anesthesia, which has sedation to such patients for radiotherapy. Venous
its own concerns in advanced ovarian cancer cannulation may be difficult in such patients. Patients
patients. There are several chemotherapeutic agents may present in an advanced stage of cancer with
approved for ovarian, fallopian tube, or primary affliction of multiple organ systems. Standard ASA
peritoneal cancer by the FDA (Food and Drug guidelines for MAC (Monitored Anesthesia Care)
Administration, USA) [41]. Amongst them, Platinum must be followed in all such cases. Anesthetic
analogues (Cisplatin, Carboplatin), Mitomycin C, management in remote locations may become a
Bevacizumab, Cyclophosphamide, Doxorubicin, challenge in such high-risk cancer patients.
Gemcitabine, Paclitaxel and Topotecan are
Conclusions
frequently prescribed in various combinations. All
these agents are prone to cause innumerable side Anesthesia for ovarian cancer surgery
effects and affect various organ systems. Hence pre- involves a thorough pre-operative assessment,
anesthetic evaluation of these patients has to be vigilant intraoperative management and meticulous
thorough and extensive. The recent development of postoperative care with extensive monitoring and
liposomal Doxorubicin Hydrochloride has reduced adequate analgesia. The major anesthetic goals
the incidence of side-effects. Anesthetic include maintaining hemodynamic stability during
considerations for patients on chemotherapy include massive fluid shifts, administering epidural
the following: Cardiac evaluation, especially analgesia, prevention of hypothermia and correction
echocardiography; Kidney function evaluation and of metabolic or electrolyte derangements. Recent
intraoperative renal protection; Intraoperative advances in surgical techniques, revision of staging
restriction of FiO2 to as minimum as possible to criteria, addition of newer chemotherapeutic agents,
avoid lung injury (Bleomycin induced oxygen novel monitoring devices, better anesthetic care and
toxicity); Complete asepsis in view of pain management has improved overall patient
immunosuppression; and Evaluation of other organ survival. In particular, the advent of HIPEC following
system functions. Radiotherapy is not used as the optimal cytoreductive surgery has opened new doors
first line for treatment of ovarian cancer, but more in the management of patients with advanced or
often to treat cancer spread [42]. External beam metastatic ovarian cancers. Nevertheless, these
radiotherapy is the mainstay of radiotherapy in have raised several issues regarding patient safety,
ovarian carcinoma. The major side-effects include which have to be addressed by the anesthesiologists
skin changes, fatigue, diarrhea, nausea and vaginal and onco-intensivists. Team effort by surgeons,
irritation. Brachytherapy is rarely used for this type of gynecologists, oncologists, anesthesiologists and
cancer. In the past, radioactive phosphorous was other supportive staff can go a long way in ensuring
used for intra-abdominal instillation, but was stopped a complete cancer cure. Interventional pain
due to intractable intestinal side-effects. physicians also have an important role in improving
Anesthesiologists may be called upon to administer

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the quality of life and providing a pain-free survival of neoadjuvant chemotherapy followed by
advanced ovarian cancer patients. interval debulking surgery in advanced
ovarian cancer. Eur J Cancer
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