ACE 20A Sample Question

Which of the following chemotherapy agents is MOST likely to prolong the effects of neuromuscular blocking agents?

A. Cyclophosphamide ✔

B. Vincristine X

C. Cisplatin X

Read the discussion below.

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Discussion

Chemotherapy is a common component of treatment for cancer, and patients presenting for anesthesia while receiving chemotherapeutics present unique challenges. Whenever possible, anesthesia should be postponed long enough for the acute effects of chemotherapy agents to resolve. Since this is not always possible, anesthesiologists should be familiar with the likely adverse effects.

Many older chemotherapeutics are immune suppressants. Therefore, patients will be at elevated risk for iatrogenic infection, and close attention to sterile technique is warranted. Most chemotherapeutics will also cause severe nausea, often necessitating high-dose antiemetics for management. Individual chemotherapeutics have a variety of specific toxicities and adverse effects. Alkylating agents such as cyclophosphamide have an anticholinesterase effect that may prolong neuromuscular blockade. While neither cisplatin nor vincristine is associated with prolongation of neuromuscular blockade, either agent can cause peripheral neuropathies. Vincristine may also cause myelotoxicity and the syndrome of inappropriate antidiuretic hormone release. Bleomycin is associated with restrictive pulmonary disease, while anthracyclines such as doxorubicin can cause permanent cardiomyopathy. 

While none of the common chemotherapeutics pose an absolute contraindication to anesthesia, knowledge of the likely adverse effects and their impact on anesthesia will be helpful when creating a plan. Newer antibody-based treatments (immune modulators) are much less likely to cause serious systemic adverse effects and may increase the safety of surgical procedures in patients who have recently undergone chemotherapy.

REFERENCE

1. Gropper MA, Cohen NH, Eriksson LI, Fleisher LA, Leslie K, Wiener-Kronish JP, eds. Miller’s Anesthesia. 9th ed. Elsevier; 2020:1056.

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