Radiation Therapy

SURGICAL SPECIALTY – Total Body Irradiation

Authors: K Dooley APRN CRNA

Surgeons: N/A

ORs: Stevenson Cancer Center

Last Update: November 5, 2020

General Considerations: Total Body Irradiation (TBI) is used to prepare patients for a bone marrow or stem cell transplant

Specific Procedures:

TBI -total body irradiation

• Patient Considerations

  • Disease Specific Considerations –

    • • • • usually for aplastic anemia or leukemias which have been resistant to chemotherapies.

      • These patients have been pretreated with chemotherapeutic agents to wipe out the bone marrow

      • Timing is crucial – if they have received the pretreating medications the radiation timing is set, they must have the radiation and then proceed the next day to receive the bone marrow or stem cell transplant.

      • The patient will receive two doses of TBI 6 hours apart, one in the morning and another in the afternoon. After discharge from PACU care in the morning the patient is transported back to the BMT unit

      • Associated Comorbidities/Syndromes

        • • • Pancytopenia

            • White count often negligible

• Case Planning

  • • Specific or Unique Room Set-Up Requirements

      • • The stretcher will be positioned next to the wall in the LINAC vault; the radiation is delivered across the room.

        • The anesthesia machine pipeline cables and suction are on the opposite side of the vault, the gas lines are long enough to reach. Several suction lines must be connected together to reach across the room.

        • The stretcher will be turned 180 degrees midway through the session to deliver radiation to both sides of the body. Do not move the anesthesia machine.

        • Utilize long TIVA drug tubing to accommodate the change of position.

        • Mount the IV infusion pump on the anesthesia machine (see pictures) and position the vital sign monitor next to the pump so that both are in the camera view.

        • Check the camera view before bringing the patient into the vault.

        • Once the patient is induced and the anesthetic is running, the radiation physicist will position the patient and check the portals by turning off all the lights in the vault! Be prepared!.

          • • The height of the stretcher cannot be changed.

            • A bolster is placed under the patient’s arm to provide a portal to the lung.

        • Airway preferred to have a native airway with the patient breathing spontaneously – nasal cannula or simple FM with continuous ETCO2 monitoring. The patient must be supine, it is fine to utilize shoulder roll or head ring to optimize the patient’s breathing, but they must not be moved once the positioning has been set by the physicist.

        • Drugs/Infusions

          • • Propofol TIVA

        • Monitors

          • • Standard ASA – EKG, NIBP, O2 sat, ETCO2

            • Monitor and infusion pump must be positioned so that they are both visible on the camera.

            • The patient will be in the LINAC radiation vault during the radiation – the anesthesia team CANNOT be in the vault during the treatment, the treatment can be suspended in the case of an emergency and the vault entered

        • Blood Availability

          • • The patient should be optimized by the oncology team prior to being sent to SCC. Communication with the managing team is critical in the days leading up to the TBI. PRBCs and platelets should be optimized prior to the day of TBI.

        • PICU Bed Availability

          • • The patient will be in-patient on the Bone Marrow Transplant unit – X200 (tenth floor)

• Anesthetic Considerations

  • • Induction

      • • • Propofol bolus with infusion aiming to maintain spontaneous ventilation

    • Positioning

      • • • supine

  • Maintenance

    • • • Maintenance of Anesthesia

          • • • TIVA with Propofol with native airway

        • Surgical Considerations (such as neuromonitoring, muscle relaxation, anticipated blood loss)

          • • • There is no surgical manipulation, no blood loss

        • Emergence/Disposition

          • • • Discontinue TIVA as soon as the radiation is complete.

              • Transfer patient to the PACU stretcher and transport with O2 and monitoring to SCC PACU (across from the radiation treatment rooms)

        • Post-Op Pain Management

          • • • none

        • Case-Specific Complications

          • • • Monitor temperature – much of the patient’s body must be exposed for measurements. Utilize plastic bags covered with towels or blankets over lower legs, feet and near head. Convective warmer cannot be used during this treatment