Anesthesia

This chapter is different than other chapters in that rather than focusing on specific organ toxicities related to immune checkpoint inhibitor (ICI) therapy, we are attempting to show how ICIs affect the care delivered by other professionals to the patients. Due to the limited anesthesiology training in medical schools, many oncologists may not have a good understanding of the scope of anesthesiologists’ work. In addition to inducing unconsciousness for surgery and procedures, we also maintain the patients’ physiologic homeostasis, protect them from pain and harmful reflexes, maintain and augment their ventilation and circulation, and provide cerebral protection. We also provide resuscitation when needed. Knowledge that a patient is receiving an ICI may significantly influence the anesthesiologist’s decision-making, so it is essential for the patient’s safety that oncologists provide good communication to all anesthesia, surgical, and procedural colleagues. This approach was suggested by our editor, Dr. Y Wang, and others in the ASCO Clinical Practice Guidelines who proposed using a wallet card [1]. We should advocate for a more complete communication - perhaps an electronic Best Practice Guideline - that could be attached to the patient electronic medical record to facilitate this. The most important information to include here would be details regarding ICI therapy. It may be well understood by the patient’s primary oncology team, but the downstream anesthesiologists may not be as familiar with the patient’s therapy, especially if the patient is treated at a different institution as is often the case in the event of emergency procedures. From the viewpoint of the anesthesiologist or surgeon, the incidence of significant side effects of ICI is sporadic as shown in the following examples: (1) a sudden cardiac death following trastuzumab cardiomyopathy which was asymptomatic prior to induction of anesthesia in a minor surgical procedure; (2) a persistent, severe hypotension in a patient undergoing cystectomy who had received pembrolizumab as neoadjuvant therapy; and (3) thoracic surgery patients on neoadjuvant ICI who may have their shrunken tumors tightly adherent to adjacent blood vessels leading to sudden and massive bleeding. Studies on the anesthetic management of patients treated with immune checkpoint inhibitors are very limited [2]. The discussion on the potential downstream consequences of specific organ toxicities and their management is described below by the ASCO Clinical Guidelines.