Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Abstract

AIMTo study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).METHODSOur study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics.RESULTSOf the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission.CONCLUSIONOverall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

“…low PCI, minimal blood loss) in a non-ICU setting. [8182] Immediate or early extubation of the trachea, epidural analgesia, postoperative monitoring in ICU, immediate initiation of parenteral nutrition in postoperative period and stringent fluid status monitoring help in favourable postoperative outcome. [83]…”

Anaesthetic management and perioperative outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: A retrospective analysis

“…In a recent review on intensive care outcomes after CRS-HIPEC,[ 29 ] the authors state that pre-operative medical co-morbidities, extent of surgical debulking (PCI), intraoperative blood losses, amount of intra-operative blood products required and total operative time are the factors affecting ICU length of stay. These were the factors that were statistically significant in predicting longer ICU stay in our cohort too.…”

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“…In this period, management of intraoperative complications and, if any, coagulopathy and / or metabolic disorders should be corrected in the early period. In order to maintain pneumatic compression initiated in the operating room for deep vein thrombosis prophylaxis until mobilization and to prevent postoperative ileus, it is important to start oral intake early and to provide postoperative pain with epidural analgesia, if possible [30][31][32].…”