Table 1 A summary of anesthetic issues in multiple myeloma

Calcium (hypercalcemia, serum Ca > 11 g/dl)

12 mg/dl — no treatment

12–14 mg/dl — chronically high levels, no treatment, acute rise, altered sensorium, treatment

> 14 mg/dl — needs treatment irrespective of duration

1) Electrocardiogram monitoring to rule out any arrythmia’s if present

2) Avoidance of drugs which cause hypercalcemia-thiazide diuretics and lithium

3) Adequate saline hydration with target 100–150 ml/h urine output

4) Avoidance of prolonged immobilization

5) Use of drugs such as calcitonin (I.M. or S.C. 4 units/kg) for initial response and zoledronate (I.V. 4 mg over 15 min)

Renal insufficiency

Creatinine clearance < 40 ml/min or serum creatinine > 2 mg/dl

Use of KIDGO bundle

1) Discontinuation of nephrotoxin agents

2) Adequate volume status and perfusion pressure

3) Use of functional hemodynamic monitoring

4) Avoidance of hyperglycemia

5) Monitoring of urine output and serum creatinine and electrolytes

Anemia

Hemoglobin < 10 g/dl or > 2 g/dl below the lower limit of normal

1) Optimized anesthesia approach — use of euvolemia, normothermia, maintenance of acid-base status, use of antifibrinolytics such as tranexamic acid

Use of normovolemic hemodilution, autologous blood transfusion, cell salvage techniques

2) Optimized surgical techniques — use of electrocautery, minimally invasive surgery, surgical sutures, staplers, topical hemostatic agents

3) Allogenic transfusion based on clinical parameters

4) Avoidance of prophylactic mild/moderate blood abnormalities

5) Use of point of care laboratory assays for transfusion of blood products

Bony lesion

The presence of osteolytic lesions on radio diagnostics such as skeletal X-ray, CT, or PET-CT

1) Gentle handling of patients during positioning, shifting, and transportation

2) Adequate padding of all pressure points

Others

Use of immunosuppressive agents

Peripheral neuropathy

1) Strict aseptic precautions

2) Appropriate institutional based prophylactic antibiotics

3) Bridging therapy of anticoagulants

4) Preoperative documentation

5) Proper padding of all pressure points