What are the anesthesia considerations for an older patient with Chronic Lymphocytic Leukemia (CLL) undergoing surgery?

Anesthesia Considerations for Older Patients with CLL Undergoing Surgery

Older patients with CLL undergoing surgery require standard anesthetic care with heightened attention to infection risk and immunocompromised status, but do not require CLL-specific anesthetic modifications unless they have significant cytopenias or are actively symptomatic.

Preoperative Assessment

Disease Status Evaluation

• Assess whether the patient has active/symptomatic CLL requiring treatment versus asymptomatic disease, as approximately 70-80% of CLL patients are asymptomatic at diagnosis and one-third never require treatment 1
• Document current CLL therapy status, particularly if the patient is on BTK inhibitors (ibrutinib, acalabrutinib, zanubrutinib) or BCL2 inhibitors (venetoclax), as these have specific perioperative implications 1, 2
• Obtain complete blood count with differential to identify cytopenias (anemia, thrombocytopenia, neutropenia) that may impact surgical risk 3, 1

Fitness Stratification

• Categorize older CLL patients into three groups: (1) fit patients suitable for standard anesthesia protocols; (2) vulnerable patients requiring modified approaches with geriatric considerations; and (3) terminally ill patients where surgery may not be appropriate 3
• Use clinical judgment supported by geriatric assessment tools to evaluate comorbidities, functional status, and autonomy, as 95% of CLL patients have at least one medical comorbidity 3, 1

Critical Laboratory Testing

• Check renal function (serum creatinine, GFR) as CLL patients may have impaired renal concentrating ability and are at risk for acute renal insufficiency perioperatively 3
• Obtain coagulation profile to assess bleeding risk, particularly in patients on targeted therapies 2
• Screen for infection given the immunocompromised state inherent to CLL, which increases complications from infections 1

Medication Management

Continue Current CLL Therapies

• BTK inhibitors should generally be continued perioperatively unless there is significant bleeding risk, as abrupt discontinuation may precipitate disease flare 1, 2
• Venetoclax can typically be continued, though coordinate with hematology for high-bleeding-risk procedures 2
• Avoid scheduling elective surgery during active infection or if the patient is febrile 3

Hematology Consultation

• Mandatory hematology involvement for patients with del(17p) or TP53 mutations, as these predict poor outcomes and may require special perioperative planning 3, 2
• Consult hematology for patients with significant cytopenias to determine if transfusion support or growth factors are needed preoperatively 3

Intraoperative Management

Standard Anesthetic Approach

• Use standard monitoring per Association of Anaesthetists guidelines including blood pressure, pulse oximetry, temperature, and capnography 3
• Either general or regional anesthesia is appropriate based on surgical requirements and patient factors; no CLL-specific contraindications exist for either technique 3
• Regional anesthesia may offer advantages including excellent postoperative analgesia and improved peripheral blood flow, though hypotension must be treated promptly with vasopressors and fluids 3

Critical Intraoperative Priorities

• Maintain normothermia using standard warming measures to prevent hypothermia-related complications 3
• Ensure adequate oxygenation and avoid hypoxia, as CLL patients may have compromised pulmonary reserve 3
• Maintain euvolemia with appropriate fluid management, as both hypovolemia and fluid overload can be problematic in patients with potential renal impairment 3

Neuromuscular Monitoring

• If neuromuscular blocking drugs are used, neuromuscular monitoring is mandatory to ensure complete reversal before extubation 3

Postoperative Management

Monitoring and Complications

• Consider HDU/ICU admission for major surgery or patients with significant comorbidities, as surgery increases risk of infection, thrombosis, and acute renal insufficiency 3
• Maintain oxygen therapy to keep SpO2 above baseline or 96% (whichever is higher) for at least 24 hours postoperatively 4
• Monitor closely for signs of infection given the immunocompromised state, and provide prophylactic antibiotics according to surgical protocols 4

Pain Management

• Use multimodal analgesia including regional blocks, patient-controlled analgesia, and oral analgesics as appropriate 3
• Employ validated pain assessment scales and reassess regularly 3, 4
• Notify the acute pain service for patients with complex pain needs or opioid tolerance 4

Thromboprophylaxis

• Implement standard thromboprophylaxis based on surgical risk assessment, as CLL patients have baseline thrombotic risk 4, 5
• Encourage early mobilization and physiotherapy to prevent venous thromboembolism 4, 5

Fluid Management

• Continue intravenous fluids until adequate oral intake is established, accounting for impaired urinary concentrating ability in CLL patients 3

Special Surgical Considerations

Day Surgery Eligibility

• Low-risk procedures in asymptomatic, well-controlled CLL patients can be performed as day surgery if standard discharge criteria are met 3
• Schedule early in the day to allow time for identification of complications before discharge 3
• Provide clear instructions about postoperative analgesia, mobilization, and emergency contact information 3

Emergency Surgery

• Emergency surgery carries higher risk; immediately notify hematology team when a CLL patient requires urgent/emergent surgery 3
• Communicate with transfusion laboratory regarding potential blood product needs 3

Key Pitfalls to Avoid

• Do not confuse CLL with sickle cell disease: The provided sickle cell guidelines 3, 6 are not applicable to CLL patients and should not guide management
• Do not delay surgery for asymptomatic CLL: Most CLL patients do not require disease-specific treatment before surgery unless they have active symptomatic disease 3, 1
• Do not withhold standard care: CLL patients receive standard anesthetic protocols; avoid over-medicalization based solely on the CLL diagnosis 3
• Do not ignore the immunocompromised state: While anesthetic technique is standard, heightened vigilance for infection is essential 1