title: Safe anesthetic management of patients undergoing a novel method of treating human hepatocellular cancer.
abstract: OBJECTIVE
  To evaluate the safety and efficacy of monitored anesthesia care (MAC) in patients who undergo a novel treatment for hepatocellular cancer in which procedure-related hemodynamic instability is problematic.
  
  
  METHODS
  Nonrandomized open study.
  
  
  METHODS
  University cancer center operating room.
  
  
  METHODS
  Nine patients scheduled for hepatic arterial infusion of doxorubicin with complete hepatic venous isolation and extracorporeal chemofiltration (no more than 3 procedures per patient).
  
  
  METHODS
  Hepatic venous isolation was achieved with a dual-balloon inferior vena cava catheter connected to an extracorporeal circuit containing chemofilters. Doxorubicin was infused through the hepatic artery and filtered from the venous blood, which was returned to the patient through an internal jugular venous catheter. Each patient received a bolus of propofol (200 micrograms/kg) and one of alfentanil (2 micrograms/kg) followed by simultaneous infusions of propofol and alfentanil for percutaneous placement of the catheters and operation of the extracorporeal circuit. Drug rates were varied to maintain a sedative-analgesic state of calm, comfort, minimal movement, and adequate respiratory function. Prior to circuit initiation, patients were preloaded with crystalloid. During circuit operation, hypotension was treated with intravenous (IV) phenylephrine and crystalloid.
  
  
  RESULTS
  End-tidal CO2 (PETCO2), respiratory rate, oxygen saturation (SaO2), arterial blood pressure (BP), and heart rate (HR) were monitored. Systolic, diastolic, and mean arterial pressure (MAP), and HR were compared before, during, and after hepatic venous isolation and chemofiltration. Doses and infusion rates of propofol, alfentanil, and phenylephrine were recorded for each treatment. Hypotension occurred in 11 of 13 procedures when blood was directed through the chemofilters and was successfully treated with phenylephrine (dose range 40 to 5,733 micrograms) and crystalloid. Blood pressure returned to the baseline value on termination of the circuit. Throughout the sedation, patients were easily arousable, analgesia was adequate, and PETCO2 level of 38 +/- 4 mmHg and SaO2 greater than 94% were maintained. Mean doses and infusion rates of MAC drugs were, respectively: propofol, 261 +/- 88 mg and 23.7 +/- 3.6 micrograms/kg/min; alfentanil, 3,350 +/- 1,468 micrograms and 0.32 +/- 0.14 microgram/kg/min.
  
  
  CONCLUSIONS
  Patients undergoing this novel cancer treatment are safely and effectively managed by MAC achieved with simultaneous infusions of alfentanil and propofol. Procedure-associated hypotension is easily treated with IV phenylephrine and crystalloid.
authors.affiliation: Department of Anesthesiology and Critical Care, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
authors.forename: T B
authors.initials: TB
authors.lastname: Dougherty
authors.forename: J A
authors.initials: JA
authors.lastname: Mikolajek
authors.forename: S A
authors.initials: SA
authors.lastname: Curley
mesh_terms: D000316:Adrenergic alpha-Agonists; D000328:Adult; D000368:Aged; D015760:Alfentanil; D000771:Anesthesia, Intravenous; D018686:Anesthetics, Intravenous; D000903:Antibiotics, Antineoplastic / Q000008:administration & dosage* / Q000627:therapeutic use*; D006528:Carcinoma, Hepatocellular / Q000188:drug therapy / Q000628:therapy*; D004317:Doxorubicin / Q000008:administration & dosage* / Q000627:therapeutic use*; D005112:Extracorporeal Circulation; D005374:Filtration; D006439:Hemodynamics / Q000187:drug effects; D006499:Hepatic Artery; D006801:Humans; D007261:Infusions, Intra-Arterial; D008875:Middle Aged; D008991:Monitoring, Physiologic; D010656:Phenylephrine; D015742:Propofol
chemical_list: D000316:Adrenergic alpha-Agonists; D018686:Anesthetics, Intravenous; D000903:Antibiotics, Antineoplastic; D015760:Alfentanil; D010656:Phenylephrine; D004317:Doxorubicin; D015742:Propofol