Background Percutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published. Methods In a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016–2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge. Results Fifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17–2.1) μg kg min-1 and fluid resuscitation volume of 5 (3–14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities. Conclusions PHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

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The communication and cooperation of widely distributed applications is enabled by conference control services for tightlycoupled environments like SCCS (Scalable Conferencing Control Service) providing a tight control of resources for application state synchronization and multipoint communication in the conference. A major issue in the design of such services is the scalability in terms of users and distribution. Especially the used resource management scheme is crucial for a high scalability. SCCS uses an own-developed scheme which improves the response time of resource requests especially if they are local in the topology. For further improvement of that scheme the reconfiguration of existing topologies is another issue. The problem of performing a reconfiguration (without blocking the conference) is not within the scope of this paper. The scope is the need for a dynamic decision how and if the conference should be reconfigured. For that a scheme is presented which detects active entities in the conference and groups them closer to each other in the topology to improve further requests. A definition of 'activity' is given together with a scheme to identify that activity during a running conference. For that, unique sets of active entities in the running conference are determined built according to the used resources in the sets. We present a placement algorithm for those active entity sets to optimize further resource requests for the specific resources used by the corresponding entity set. A scheme is presented which is the basis for the decision to perform a reconfiguration and it is embedded in the conferencing service SccS. Additionally a performance evaluation is presented using an automata-based load model to determine the performance gain in different scenarios.

ZusammenfassungDie perkutane hepatische Perfusion mit dem Chemotherapeutikum Melphalan (PHMP) ist eine Letztlinientherapie bei Patienten mit inoperablen primären oder sekundären Lebertumoren. Dabei wird die Leber transarteriell mit Melphalan perfundiert und aufgesättigt (Chemosaturation), mit dem Ziel, die Lebertumoren selektiv und ohne dessen systemische zytotoxische Eigenschaften zu behandeln. Über einen Extrakorporalkreislauf und eine Ballonokklusion der V. cava inferior wird das venöse hepatische Blut hämofiltriert und venös zurückgeleitet. Verfahrensbedingt kommt es dabei zu einer ausgeprägten Kreislaufdepression und einer Störung der plasmatischen Gerinnung. In diesem Artikel wird das anästhesiologische und postinterventionelle Management bei Patienten mit PHMP beschrieben und auf Fallstricke und Besonderheiten hingewiesen.