What preoperative medications are recommended for an adult patient with liver cancer undergoing Transarterial Chemoembolization (TACE)?

TACE Preoperative Medications

For adult patients undergoing TACE for hepatocellular carcinoma, preoperative medications should include prophylactic antibiotics (cefazolin 2g IV single dose or fluoroquinolone) for patients with biliary risk factors, and intra-arterial lidocaine (up to 100 mg) plus nitroglycerin (≤100 μg) administered during the procedure to reduce pain and prevent vasospasm. 1, 2

Antibiotic Prophylaxis

Risk Stratification

• Patients with biliary risk factors require prophylactic antibiotics to prevent post-TACE liver abscess, which occurs in 0.1-4.5% of cases 1, 2
• Biliary risk factors include: biliary obstruction, bilioenteric anastomosis, or biliary stent 2
• In current practice, 49.1% of hepatologists use prophylactic antibiotics for all or selected cases 2

Recommended Regimens

• First-line: Cefazolin 2g IV as a single dose 2
• Alternative: Fluoroquinolones - levofloxacin 300-500mg oral or IV, or moxifloxacin 400mg oral or IV 2
• Moxifloxacin demonstrated 100% prevention of liver abscess in retrospective studies 2
• Total antibiotic duration should not exceed 5-7 days from the time of TACE 2, 3

Important Caveats

• Do not extend prophylactic antibiotics beyond 5-7 days - prolonged courses beyond two weeks provide no additional benefit 2, 3
• Target pathogens include gram-negative bacilli (E. coli, Enterobacter cloacae, Klebsiella pneumoniae), Enterococcus faecalis, Staphylococcus aureus, and Staphylococcus epidermidis 1, 2
• Metronidazole is not indicated for standard TACE prophylaxis and should not be added to the regimen 3

Intra-Arterial Medications During TACE

Lidocaine for Pain Control

• Administer intra-arterial lidocaine up to 100 mg (10 mL of 1% lidocaine) PRIOR to chemoembolic agent injection 1
• An RCT with 113 patients demonstrated that lidocaine given before chemoembolic agents significantly reduced narcotic requirements post-TACE, while administration after chemoembolic agents did not 1
• Preemptive lidocaine is especially important for:
  • Patients requiring high doses of chemoembolic agents 1
  • Young patients 1
  • Patients without chronic liver disease 1

Critical Safety Warning

• Excessive lidocaine may cause serious cardiac arrhythmia - do not exceed 100 mg per procedure 1

Nitroglycerin for Vasospasm Prevention

• Administer intra-arterial nitroglycerin ≤100 μg per tumor-feeding artery preemptively to prevent vasospasm 1
• Vasospasm can diminish or block hepatic arterial flow when the microcatheter stimulates the artery, hampering delivery of chemoembolic agents 1
• Particularly useful during infusion of particulate embolic materials such as drug-eluting beads 1

Critical Safety Warning

• Excessive nitroglycerin may cause serious hypotension - do not exceed 100 μg per tumor-feeding artery 1

Sedation Considerations

Midazolam Dosing (if used)

• For preoperative sedation/anxiolysis in good risk adult patients below age 60: 0.07 to 0.08 mg/kg IM (approximately 5 mg) administered up to 1 hour before procedure 4
• For IV sedation: Initial dose of 0.5-2 mg given over 2 minutes, with additional 1 mg increments every 2+ minutes as needed 4
• Patients over 60 years, with COPD, or receiving concurrent CNS depressants require dose reduction 4

Monitoring Requirements

• Continuous monitoring of respiratory and cardiac function (pulse oximetry) is mandatory regardless of sedation level 4
• Immediate availability of resuscitative drugs and equipment with personnel skilled in airway management 4

Post-Procedure Symptom Management

Pain Control

• Tramadol or tramadol+acetaminophen is most commonly used (72.7% of practitioners) 1
• Opioids (50.9%), acetaminophen (43.6%), and NSAIDs (23.6%) are alternative options 1
• Post-procedure pain occurs in most patients, with >25% experiencing moderate to severe pain (VAS ≥4/10) 1

Antiemetic Therapy

• 5-HT3 receptor antagonists (used by 70.9% of practitioners) 1
• Metoclopramide (80.0% usage) 1
• Dexamethasone and NK-1 receptor antagonists are also recommended 1
• Nausea and vomiting prevalence is 40.3-52.5% and can cause dehydration, electrolyte imbalance, and extended hospitalization 1

Common Pitfalls to Avoid

• Do not administer intra-arterial lidocaine AFTER chemoembolic agents - it must be given before to be effective 1
• Do not exceed maximum safe doses of lidocaine (100 mg) or nitroglycerin (100 μg per artery) due to serious adverse event risk 1
• Do not add metronidazole to prophylaxis regimens - it is not indicated and adds unnecessary antibiotic exposure 3
• Do not continue prophylactic antibiotics beyond 5-7 days - this provides no benefit and increases resistance risk 2, 3
• Do not use bleomycin for TACE - it lacks guideline support and carries pulmonary toxicity risks 5