Anesthesia Considerations During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
Summary by Boris Ladyzhensky, MD 9.28.24
https://www.sciencedirect.com/science/article/abs/pii/S105532071200052X
Key points for the perioperative management of these patients are listed below:
Induced hyperthermia results in increased myocardial oxygen demand, and intra-operative administration of high volumes of fluid can further exacerbate or precipitate pulmonary edema. Therefore, cytoreductive surgery with HIPEC should be considered as a procedure that presents elevated cardiac risk.
Rapid sequence induction with video-laryngoscopy is commonly used as a first-line technique for endotracheal intubation. An arterial line is always placed. The routine placement of central venous catheters is no longer performed unless indicated for vascular access.
The hyperdynamic, vasodilated circulatory state is characterized by a steady increase in HR and CO that reaches its maximum between 70 to 80 minutes of the 90-minute heated chemotherapy phase. This can last for 10 minutes after the chemotherapeutic lavage is concluded.
The use of long-acting antihypertensives is avoided because of the dynamic nature of the procedure. Heart rate is generally maintained at lower than 90 beats per minute.
Continuous noninvasive cardiac output monitoring, as well as urine output, is used to guide fluid administration throughout the procedure. Transfusion with pRBC is rarely necessary, as typical estimated blood loss averages 300 to 500 mL.
Because some chemotherapeutic agents are nephrotoxic, maintenance of steady urine output is encouraged. Unfortunately, it is not known to what degree urine output must be maintained. Commonly accepted goals range from 50 to 100 mL for every 15 minutes of the hyperthermic infusion. Low-dose dopamine infusion may be initiated 15 to 30 minutes before infusion of mitomycin C, and is infused only for the duration of heated perfusion. Furosemide should be administered only when urine output is inadequate despite confirmation of adequate intravascular volume and renal perfusion.
The surgeon or perfusionist should decrease the temperature of the perfusate when the core temperature approaches 39C. Of note, there may be disparity of temperature measurements depending on the temperature probe site. Additional heat transfer to the patient should be avoided during the heated chemotherapy phase.
Approximately 15 minutes before the start of heated infusion, a set of laboratory studies is obtained, including chemistries, arterial blood gas, and hemoglobin. Many patients will require electrolyte replacement, most commonly calcium, magnesium, and potassium. Therefore, rechecking electrolytes after the chemotherapy phase of the procedure is advised.
Take Home Message:
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive, invasive procedure that presents unique physiologic challenges.
During the HIPEC portion of the surgery, patients develop a hyperdynamic state.
A balanced approach to fluid management, which incorporates both crystalloids and colloids, is encouraged.
Hemodynamic monitoring with estimation of cardiac output is useful for optimizing organ perfusion while preventing fluid overload.
To avoid renal injury by chemotherapeutic agents, urine output should be maintained at a high rate during that phase of the procedure.
Thoracic epidural anesthesia improves analgesia and facilitates early mobilization of patients.