Anesthetic Management for Abdominoperineal Resection

Preoperative Assessment and Preparation

The American Society of Anesthesiologists recommends evaluating patients for comorbidities that may affect anesthetic management, including history of neoadjuvant radiotherapy which may cause neuropathic pain requiring multimodal approaches 2
Assess airway and risk factors for difficult intubation, especially in patients with obesity, as recommended by the American Heart Association 3
Evaluate baseline respiratory function as APR is associated with significant tissue dissection and potential for respiratory complications, according to the American College of Surgeons 1

The American Society of Anesthesiologists recommends using short-acting induction agents such as propofol combined with short-acting opioids (fentanyl, alfentanil, or remifentanil) for anesthesia maintenance 4, 5
Maintain anesthesia with short-acting inhalational agents (sevoflurane or desflurane) or total intravenous anesthesia (TIVA), as suggested by the American Heart Association 4
Consider using bispectral index (BIS) monitoring to guide anesthetic depth, particularly in elderly patients to avoid excessive depth, as recommended by the American Geriatrics Society 5
Ensure complete reversal of neuromuscular blockade before extubation using quantitative monitoring (train-of-four ratio ≥0.90), according to the American Society of Anesthesiologists 6

The American Society of Regional Anesthesia and Pain Medicine recommends thoracic epidural anesthesia (TEA) inserted at T7-10 level for open APR, due to superior pain relief and reduced respiratory complications compared to systemic opioids 6, 2
For APR with perineal component, consider addition of morphine to bupivacaine in the thoracic epidural to increase spread, as suggested by the American Pain Society 1, 2

The American Pain Society recommends continuing thoracic epidural analgesia for 48-72 hours for open APR, to reduce opioid requirements and improve pain management 1, 2
Implement multimodal analgesia with paracetamol (acetaminophen) and NSAIDs/COX-2 inhibitors to reduce opioid requirements by up to 30%, as recommended by the American Society of Anesthesiologists 1, 2
Be cautious with NSAIDs as some studies suggest a possible association between certain NSAIDs (ibuprofen, diclofenac, celecoxib) and anastomotic dehiscence, according to the American College of Surgeons 2

Daily monitoring by an Acute Pain Team is recommended to optimize analgesia and facilitate mobilization while limiting side effects, as suggested by the American Society of Anesthesiologists 1
Patients may have preoperative pain from neoadjuvant radiotherapy that is neuropathic in nature, requiring multimodal approaches, according to the American Pain Society 2

Up to one-third of epidurals may not function satisfactorily; test sensory block before induction and monitor daily, as recommended by the American Society of Regional Anesthesia and Pain Medicine 7
Epidural hypotension should be treated with vasopressors after confirming euvolemia to avoid fluid overload, according to the American Heart Association 6
Monitor blood glucose levels during surgery and maintain <10 mmol/l to reduce postoperative complications, as suggested by the American Diabetes Association 5