Anaesthetic Considerations in the Perioperative Management of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Abstract

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has emerged as one of the primary modalities of treatment of diffuse peritoneal malignancies. It is a complex surgical procedure with the patients facing major and potentially life threatening alterations of haemodynamic, respiratory, metabolic and thermal balance with significant fluid losses and the perioperative management is challenging for anaesthesiologists and intensive care physicians. Though the alterations are short lived, these patients require advanced organ function monitoring and support perioperatively. The anaesthesiologist is involved in the management of haemodynamics, respiratory function, coagulation, haematologic parameters, fluid balance, thermal variations, and metabolic and nutritional support perioperatively. The chemotherapy instillate used are known to cause nephrotoxicity, cardiotoxicity, dyselectrolytemia and lactic acidosis. The preoperative polypharmacy for pain control, previous surgery and/or chemotherapy, malnourished status secondary to feeding problems and tumour wasting syndrome make the task all the more challenging. The anaesthesiologist also needs to consider the perioperative care from a quality of life perspective and proper preoperative counselling is important. The present overview summarizes the challenges faced by the anaesthesiologist regarding the pathophysiological alterations during the Cytoreductive surgery and Hyperthermic intraperitoneal chemotherapy in the preoperative, intraoperative and postoperative periods.

New transpulmonary thermodilution approach to assess hemodynamic changes in patients undergoing open abdominal cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

“…Intraoperative hemodynamic monitoring is multilateral, and across studies on cytoreductive surgery with HIPEC, the monitoring approaches used include at least an invasive central venous and arterial pressure line, and hourly fluid administration and urine amount assessment [26,27]. However, the CVP and amount of urine are not accurate indices of fluid responsiveness and only help to detect a patient's intravascular volume status [28][29][30]. In addition, both pulse pressure variation and SVV, which may exhibit faster responses to sudden changes in volume responsiveness, are calculated using an arterial pressure waveform analysis method.…”

“…During HIPEC, the circulation support with inotropes/vasopressors does not have definite recommendations [28]. The common practice in the setting of vasodilation was the use of noradrenaline and methoxamine, and it usually depends on institutional protocols.…”

Cytoreductive onco-surgery with combined hyperthermic intraperitoneal chemotherapy and hyperthermic intrathoracic chemotherapy: Perioperative challenges

“…[ 13 ] Protein loss can occur and albumin supplementation might be needed. [ 14 ] Renal dysfunction, dyselectrolytemia, and hyperglycemia can occur especially in first 48 h.[ 15 ] Serum electrolytes (sodium, potassium, calcium, magnesium) are to be measured periodically and replaced. Mechanical thromboprophylaxis should be used to prevent DVT and pharmacological agents can be started as soon as the bleeding risk and coagulopathy resolve.…”

Anesthetic implications in hyperthermic intraperitoneal chemotherapy

“…This may lead to basal atelactasis and predispose the patients to increased risk of postoperative respiratory complications. Intensive spirometry should be prescribed in the preoperative period to reduce the incidence of pulmonary complications[ 22 ] Patients undergoing HIPEC surgeries are at increased risk of venous thrombo-embolism (VTE) and a decision to start VTE prophylaxis (preoperatively and 4-6 weeks postoperatively) using heparin (low molecular weight/unfractionated) and/or mechanical pneumatic compression stockings should be taken Pulmonary function assessment and management: These patients may have ascites and pleural effusion which leads to diaphragmatic splinting and basal atelectasis and predispose them to hypoxia in preoperative period. A detailed medical history and investigations (CXR/CT, arterial blood gas (ABG) analysis, pulmonary function tests, cardiopulmonary exercise testing (CPET) if feasible should be done to determine pulmonary function.…”

“…This may lead to basal atelactasis and predispose the patients to increased risk of postoperative respiratory complications. Intensive spirometry should be prescribed in the preoperative period to reduce the incidence of pulmonary complications[ 22 ] Patients undergoing HIPEC surgeries are at increased risk of venous thrombo-embolism (VTE) and a decision to start VTE prophylaxis (preoperatively and 4-6 weeks postoperatively) using heparin (low molecular weight/unfractionated) and/or mechanical pneumatic compression stockings should be taken …”