A Randomized Trial of Goal Directed vs Standard Fluid Therapy in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Abstract

The use of adequate fluid therapy during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. The aim of the study was to assess whether the use of fluid therapy protocol combined with goal-directed therapy (GDT) is associated with a significant change in morbidity, length of hospital stay, and mortality compared to standard fluid therapy. Patients American Society of Anesthesiologists (ASA) II-III undergoing CRS and HIPEC were randomized into two groups. The GDT group (N = 38) received fluid therapy according to a protocol guided by monitored hemodynamic parameters. The control group (N = 42) received standard fluid therapy. We evaluated incidence of major complications, total length of hospital stay, total amount of fluids administered, and mortality rate. The incidence of major abdominal complications was 10.5% in GDT group and 38.1% in the control group (P = 0.005). The median duration of hospitalization was 19 days in GDT group and 29 days in the control group (P < 0.0001). The mortality rate was zero in GDT group vs. 9.5% in the control group (P = 0.12). GDT group received a significantly (P < 0.0001) lower amount of fluid (5812 ± 1244 ml) than the control group (8269 ± 1452 ml), with a significantly (P < 0.0001) lower volume of crystalloids (3884 ± 1003 vs. 68,528 ± 1413 ml). In CRS and HIPEC, the use of a GDT improves outcome in terms of incidence of major abdominal and systemic postoperative complications and length of hospital stay, compared to standard fluid therapy protocol.

A review of 111 anaesthetic patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

“…(9) Compared to standard fluid therapy, goal-directed therapy using noninvasive cardiac output monitors has been found to result in lower amounts of administered fluid (5.8 L vs. 8.3 L) for patients undergoing CRS and HIPEC. (10) As a result, there was an 18% reduction in risk of abdominal complications, such as infection and anastomotic dehiscence, as well as a ten-day reduction in length of hospitalisation. (10) The pulmonary artery catheter (Swan-Ganz CCOmbo; Edwards Life Sciences, Unterschleissheim, Germany) was not used in our series, as its utility did not justify the potential complications.…”

“…(10) As a result, there was an 18% reduction in risk of abdominal complications, such as infection and anastomotic dehiscence, as well as a ten-day reduction in length of hospitalisation. (10) The pulmonary artery catheter (Swan-Ganz CCOmbo; Edwards Life Sciences, Unterschleissheim, Germany) was not used in our series, as its utility did not justify the potential complications. While pulmonary artery catheters can furnish fascinating physiological data, they have not been shown to alter outcomes.…”

The added value of cardiac index and pulse pressure variation monitoring to mean arterial pressure-guided volume therapy in moderate-risk abdominal surgery (COGUIDE): a pragmatic multicentre randomised controlled trial

“…Goal‐directed therapy is frequently applied with the intention to optimise peri‐operative haemodynamic profiles and maximise oxygen delivery in patients undergoing abdominal surgery . The beneficial effects of goal‐directed therapy on outcome have been investigated predominately in patients with a high‐risk profile undergoing major procedures .…”

Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy, Part II: Implementation

“…Adequate fluid administration helps counteract blood, other body fluid, and protein losses and reduce the risk of tissue hypoperfusion and intra‐abdominal pressure . Increasing circulating volume during CRS while preventing fluid overload, which can cause tissue edema and cardiac and pulmonary complications, is paramount. Providers also should understand that a restrictive fluid‐therapy approach may increase postoperative complications, such as acute pulmonary edema and cerebral edema .…”

“…The liberal‐versus‐restrictive fluid‐therapy approach is a goal‐directed approach rather than a nontargeted, conventional fluid‐therapy approach. Goal‐directed therapy may reduce hospital length of stay, postoperative complications, and mortality in patients undergoing CRS with HIPEC …”