title: Anaesthetic management during open and percutaneous irreversible electroporation.
abstract: BACKGROUND
  Irreversible electroporation (IRE) is a novel tumour ablation technique involving repetitive application of electrical energy around a tumour. The use of pulsed electrical gradients carries a risk of cardiac arrhythmias, severe muscle contractions, and seizures. We aimed to identify IRE-related risks and the appropriate precautions for anaesthetic management.
  
  
  METHODS
  All patients who were treated with IRE were prospectively included. Exclusion criteria were arrhythmias, congestive heart failure, active coronary artery disease, and epilepsy. All procedures were performed under general anaesthesia with complete muscle relaxation during ECG-synchronized pulsing. Adverse events, cardiovascular effects, blood samples, cerebral activity, and post-procedural pain were analysed.
  
  
  RESULTS
  Twenty-eight patients underwent 30 IRE sessions for tumours in the liver, pancreas, kidney, and lesser pelvis. No major adverse events occurred during IRE. Median systolic and diastolic blood pressure increased by 44 mm Hg (range -7 to 108 mm Hg) and 19 mm Hg (range 1-50 mm Hg), respectively. Two transient minor cardiac arrhythmias without haemodynamic consequences were observed. Muscle contractions were mild and IRE caused no reactive brain activity on a simplified EEG. Pain in the first 24 h after percutaneous IRE was generally mild, but higher pain scores were reported after pancreatic treatment (mean VAS score 3; range 0-9).
  
  
  CONCLUSIONS
  Side-effects during IRE on tumours in the liver, pancreas, kidney, and lesser pelvis seem mild and manageable when current recommendations for anaesthesia management, including deep muscle relaxation and ECG synchronized pulsing, are followed. Electrical pulses do not seem to cause reactive cerebral activity and evidence for pre-existing atrial fibrillation as an absolute contra-indication for IRE is questionable.
authors.affiliation: Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: K
authors.initials: K
authors.lastname: Nielsen
authors.affiliation: Department of Radiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: H J
authors.initials: HJ
authors.lastname: Scheffer
authors.affiliation: Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: J M
authors.initials: JM
authors.lastname: Vieveen
authors.affiliation: Department of Radiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: A A J M
authors.initials: AA
authors.lastname: van Tilborg
authors.affiliation: Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: S
authors.initials: S
authors.lastname: Meijer
authors.affiliation: Department of Radiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: C
authors.initials: C
authors.lastname: van Kuijk
authors.affiliation: Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: M P
authors.initials: MP
authors.lastname: van den Tol
authors.affiliation: Department of Radiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
authors.forename: M R
authors.initials: MR
authors.lastname: Meijerink
authors.affiliation: Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands Department of Anaesthesiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven ra.bouwman@gmail.com.
authors.forename: R A
authors.initials: RA
authors.lastname: Bouwman
mesh_terms: D055011:Ablation Techniques / Q000009:adverse effects / Q000379:methods*; D000368:Aged; D000768:Anesthesia, General / Q000379:methods*; D001145:Arrhythmias, Cardiac / Q000209:etiology; D000075202:Contraindications; D004562:Electrocardiography; D004569:Electroencephalography; D018274:Electroporation / Q000379:methods*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000209:etiology; D007680:Kidney Neoplasms / Q000601:surgery; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D016343:Monitoring, Intraoperative / Q000379:methods; D009119:Muscle Contraction; D009369:Neoplasms / Q000601:surgery*; D010147:Pain Measurement / Q000379:methods; D010149:Postoperative Pain / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000601:surgery; D010386:Pelvic Neoplasms / Q000601:surgery; D019990:Perioperative Care / Q000379:methods; D011446:Prospective Studies
keywords: EEG, electroencephalography; ablation techniques; anaesthesia, general; electroporation, methods; liver neoplasms, surgery; pancreatic neoplasms, surgery