1
|
Lundbech M, Damsbo M, Krag AE, Hvas AM. Changes in Coagulation in Cancer Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Treatment (HIPEC)-A Systematic Review. Semin Thromb Hemost 2024; 50:474-488. [PMID: 36828005 DOI: 10.1055/s-0043-1764125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Venous thromboembolism and postoperative bleeding are complications of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this systematic review was to summarize current knowledge on the effect of cytoreductive surgery with HIPEC on coagulation and fibrinolysis within 10 days after surgery. Studies were identified in PubMed, Embase, and Web of Science on December 12, 2022. Data on biomarkers of coagulation and fibrinolysis measured preoperatively up to the 10th postoperative day were extracted. Among 15 included studies, 13 studies reported markers of primary hemostasis. Eleven studies found reduced platelet count following cytoreductive surgery with HIPEC and two studies reported reduced platelet function. Twelve studies reported impaired secondary hemostasis until postoperative day 10 indicated by prolonged international normalized ratio, prothrombin time, and activated partial thromboplastin time. Fibrinogen was decreased in three studies from preoperative to postoperative day 3 switching to increased levels until postoperative day 10. In accordance, three studies found reduced maximum amplitude and maximum clot firmness by thromboelastography/thromboelastometry (ROTEM/TEG) on the first postoperative day indicating impaired clot strength. Four studies demonstrated increased d-dimer, factor (F) VIII, and thrombin generation during the 10 postoperative days. Four studies investigated fibrinolysis by ROTEM/TEG and plasminogen activator inhibitor-1 (PAI-1) after cytoreductive surgery with HIPEC reporting contradictive results. In conclusion, a decrease in platelet count and subtle changes in secondary hemostasis were found following cytoreductive surgery with HIPEC. Data on the effect of cytoreductive surgery with HIPEC on fibrinolysis are sparse and this needs to be further investigated.
Collapse
Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matilde Damsbo
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | |
Collapse
|
2
|
Kim JH, Park KN, Park EY, Jang MJ, Park YJ, Kim Y, Chang SJ, Park SY, Yun JY, Lim MC. Impact of warm saline irrigation, hyperthermic intraperitoneal chemotherapy on postoperative pain in primary ovarian cancer from the KOV-HIPEC-01 randomized trial. Gynecol Oncol 2023; 177:32-37. [PMID: 37634257 DOI: 10.1016/j.ygyno.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a treatment option at the time of cytoreductive surgery after neoadjuvant chemotherapy. The effect of active warming of HIPEC on postoperative pain needs to be investigated. This study aimed to investigate whether HIPEC reduces postoperative pain. METHODS From the KOV-HIPEC-01 trial, a randomized controlled trial of HIPEC for advanced primary ovarian cancer, 184 patients with a residual tumor size <1 cm were randomly assigned to the HIPEC and control groups at a 1:1 ratio. The consumption of analgesics and pain scales were analyzed. Hyperthermic intraperitoneal chemotherapy was administered after cytoreductive surgery. The primary objective was to compare the consumption of opioids measured in morphine milligram equivalents and non-opioids measured as the maximum daily dose between the HIPEC and control groups. The secondary objective was to compare the minimum and maximum pain intensities on numeric rating scales between the two groups using a linear mixed model. RESULTS Lesser consumption of non-opioids, with a lower mean maximum daily dose on postoperative days 1 and 2, was observed. The HIPEC group also experienced lower maximum pain intensities on postoperative day 1. No overall differences in the minimum or maximum pain intensities were observed on postoperative day 7. CONCLUSION The addition of HIPEC to cytoreductive surgery did not lead to increased postoperative pain, as demonstrated by a reduction in the use of analgesics and lower scores on postoperative pain scales during the early postoperative period.
Collapse
Affiliation(s)
- Ji Hyun Kim
- Center for Gynecologic Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Kyung Nam Park
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea; Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Eun Young Park
- Biostatistics Collaboration Team, National Cancer Center, Goyang, Republic of Korea
| | - Min Jung Jang
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Yoen Jung Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youseok Kim
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sang-Yoon Park
- Center for Gynecologic Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Jung Yeon Yun
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang, Republic of Korea.
| | - Myong Cheol Lim
- Center for Gynecologic Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea; Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Division of Rare and Refractory Cancer, Research Institute, National Cancer Center, Goyang, Republic of Korea; Center for Clinical Trials, Hospital, National Cancer Center, Goyang, Republic of Korea.
| |
Collapse
|
3
|
Pintado MC, Lasa Unzúe I, Gómez Sanz R, Diez Alonso M, Ortega MA, Álvarez de Mon M, Nevado Losada E, Gutierrez Calvo A. Hematological Alterations after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. J Clin Med 2023; 12:4323. [PMID: 37445361 DOI: 10.3390/jcm12134323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have benefits for survival in some cancers with peritoneal metastasis. Hematologic toxicity described rate is 2 to 38%. METHODS Patients admitted to an intensive care unit (ICU) after CRS and HIPEC over 78 months. The data recorded were demographic characteristics, the severity of illness, complete blood samples, the type of cancer and extension, HIPEC drug and temperature, ICU and hospital stay and mortality, bleeding, and the need for transfusion of blood products. RESULTS Of the 96 patients included, 77.1% presented hematological complications: 8.3% leukopenia (<4000/mm3 leucocytes), 66.7% anemia (hemoglobin < 10 mg/dL), and 22.9% coagulopathy (INR < 1.5, or/and aPTT < 45 s, or/and platelet count < 100,000/mm3, or/and <100 mg/dL of serum fibrinogen). Leukopenia was higher in ovarian cancer or those treated with doxorubicin. Females with anemia, ovarian cancer, and those treated with cisplatin or doxorubicin had longer ICU stays. Bleeding complications were low-corrected in a conservative manner. The median ICU stay was 5 (4.0-5.0) days. The ICU mortality rate was 1.0%. CONCLUSIONS In our study, 77.1% of patients treated with CRS and HIPEC developed hematological complications during the postoperative period; the majority of them were not severe and resolved spontaneously, without an effect on mortality or hospital stay.
Collapse
Affiliation(s)
- Maria Consuelo Pintado
- Intensive Care Unit, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Inmaculada Lasa Unzúe
- Department of General and Digestive Surgery, General and Digestive Surgery, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
| | - Remedios Gómez Sanz
- Department of General and Digestive Surgery, General and Digestive Surgery, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
| | - Manuel Diez Alonso
- Department of General and Digestive Surgery, General and Digestive Surgery, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
| | - Miguel A Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Melchor Álvarez de Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Inmune System Diseases-Rheumatology and Internal Medicine Service, Hospital Universitario Príncipe de Asturias (CIBEREHD), 28806 Alcalá de Henares, Spain
| | - Emilio Nevado Losada
- Intensive Care Unit, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
| | - Alberto Gutierrez Calvo
- Department of General and Digestive Surgery, General and Digestive Surgery, Hospital Universitario Príncipe de Asturias, 28805 Alcalá de Henares, Spain
| |
Collapse
|
4
|
Fidkowski CW, Hussain A, Younger JD, Giska MA, McCurry C, Loyd GE. Erector Spinae Plane Catheters for Analgesia for Cytoreduction Surgery With Hyperthermic Intraperitoneal Chemotherapy: A Case Series. A A Pract 2022; 16:e01643. [PMID: 36599010 DOI: 10.1213/xaa.0000000000001643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is a complex and painful procedure that can cause postoperative hypotension and coagulopathy. Epidural analgesia may worsen hypotension and is contraindicated in the setting of coagulopathy. While alternative regional techniques are being explored, the use of erector spinae plane blocks has not been reported. We present a case series of 6 patients who had erector spinae plane catheters for cytoreduction surgery with hyperthermic intraperitoneal chemotherapy. They remained stable intraoperatively and had adequate pain control postoperatively. Erector spinae plane catheters may be a suitable alternative for epidural analgesia for these patients.
Collapse
Affiliation(s)
- Christina W Fidkowski
- From the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Hospital, Detroit, Michigan
| | | | | | | | | | | |
Collapse
|
5
|
HIPEC as a risk factor for postoperative coagulopathy after cytoreductive surgery for peritoneal metastases. Updates Surg 2022; 74:1715-1723. [PMID: 35932406 DOI: 10.1007/s13304-022-01340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
AIM OF THE STUDY Postoperative coagulopathy is a poorly investigated condition after Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). This study aims to evaluate the occurrence and risk factors of coagulative disorders after surgery for peritoneal metastases. PATIENTS AND METHODS The records were extracted from a prospectively maintained database of consecutive patients who underwent CRS between January 2018 and September 2020. The study was approved by the local Ethics Committee. For each patient, the coagulation profile (CP), which included international normalized ratio (INR), partial thromboplastin time (aPTT), and platelets (PLTS) before surgery, intensive care unit admission,1st, 3rd, 5th postoperative day (POD) and the day before discharge was collected. Risk factors for postoperative coagulopathy were identified at multivariate analysis. RESULTS During the study period, 125 patients were included in the study. Among these, 48 (38.4%) underwent CRS only, and 77 (61.6%) CRS followed by HIPEC. Twenty-one patients (16.8%) developed severe coagulopathy, 5 (10.4%) after CRS and 16 (20.8%) after CRS-HIPEC. At multivariate analysis, HIPEC and blood loss ≥ 500 ml represented independent risk factors for severe alteration of INR > 1.5 (p = 0.05, OR 1.2) and PLTS < 75 109/L (p = 0.03, OR 1.3), respectively. CONCLUSION HIPEC is an independent risk factor for postoperative coagulopathy after CRS. Further studies are necessary to assess the usefulness of the point-of-care test in patients treated with CRS-HIPEC.
Collapse
|
6
|
Gupta R, Gupta N, Sirohiya P, Pandit A, Ratre BK, Vig S, Bhan S, Singh R, Kumar B, Bhopale S, Mishra S, Garg R, Bharati SJ, Kumar V, Deo S, Bhatnagar S. Perioperative anaesthetic management in cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC): a retrospective analysis in a single tertiary care cancer centre. Pleura Peritoneum 2022; 7:127-134. [PMID: 36159215 PMCID: PMC9467899 DOI: 10.1515/pp-2022-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/03/2022] [Indexed: 12/05/2022] Open
Abstract
Objectives Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with increased morbidity and mortality. We retrospectively analysed the perioperative anesthetic management in patients undergoing HIPEC surgery. Methods After ethics approval, we reviewed the records of patients who underwent CRS/HIPEC from 2015 until 2020. We noted the peritoneal carcinomatosis index (PCI), blood loss, anastomoses done, total amount of fluid given, delta temperature and duration of surgery. These were correlated with the need for postoperative ventilation, length of ICU stay, Clavien–Dindo score and 30 day mortality. Results Of the 180 patients reviewed, the majority were women (85%) with a mean age of 48 years who had ovarian tumors (n=114). The total amount of fluid given was associated with an increased length of ICU stay (p=0.008). Prolonged surgery resulted in increased length of ICU stay (p<0.001), need for postoperative ventilation (p=0.006) and a poor Clavien–Dindo score (p=0.039). A high PCI score correlated with increased ICU stay, 30 day mortality (p<0.001), and the need for postoperative ventilation (0.005). Conclusions PCI, duration of surgery and blood loss were major predictors of postoperative morbidity. Additionally, the amount of fluid given and delta temperature affected patient outcome and should be individualized to the patient’s needs.
Collapse
Affiliation(s)
- Raghav Gupta
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Nishkarsh Gupta
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Prashant Sirohiya
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Anuja Pandit
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Brajesh Kumar Ratre
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Saurabh Vig
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Swati Bhan
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Ram Singh
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Balbir Kumar
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Shweta Bhopale
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Seema Mishra
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Rakesh Garg
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | | | - Vinod Kumar
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| | - Suryanarayana Deo
- Department of Surgical Oncology , All India Institute of Medical Sciences , New Delhi , India
| | - Sushma Bhatnagar
- Department of Onco-anesthesia and Palliative Medicine , AIIMS , New Delhi , India
| |
Collapse
|
7
|
Current Trends in Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Disease from Appendiceal and Colorectal Malignancies. J Clin Med 2022; 11:jcm11102840. [PMID: 35628966 PMCID: PMC9143396 DOI: 10.3390/jcm11102840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/10/2022] Open
Abstract
Peritoneal carcinomatosis (PC) is a poor prognostic factor for all malignancies. This extent of metastatic disease progression remains difficult to treat with systemic therapies due to poor peritoneal vascularization resulting in limited drug delivery and penetration into tissues. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are surgical interventions that directly target peritoneal tumors and have improved outcomes for PC resulting from appendiceal and colorectal cancer (CRC). Despite these radical therapies, long-term survival remains infrequent, and recurrence is common. The reasons for these outcomes are multifactorial and signal the need for the continued development of novel therapeutics, techniques, and approaches to improve outcomes for these patients. Here, we review landmark historical studies that serve as the foundation for current recommendations, recent discoveries, clinical trials, active research, and areas of future interest in CRS/HIPEC to treat PC originating from appendiceal and colorectal malignancies.
Collapse
|
8
|
Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review. Curr Pain Headache Rep 2022; 26:1-13. [PMID: 35118596 DOI: 10.1007/s11916-022-00998-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). RECENT FINDINGS Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.
Collapse
|
9
|
Song J, Choi N, Kang M, Ji SM, Kim DW, Kwon MA. Analgesic effects of ultrasound-guided four-quadrant transabdominal plane block in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study. Anesth Pain Med (Seoul) 2022; 17:75-86. [PMID: 35139610 PMCID: PMC8841264 DOI: 10.17085/apm.21094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background Postoperative pain occurring after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is difficult to control because of extensive surgical injuries and long incisions. We assessed whether the addition of a four-quadrant transabdominal plane (4Q-TAP) block could help in analgesic control. Methods Seventy-two patients scheduled to undergo elective CRS with HIPEC and intravenous patient-controlled analgesia (IV PCA) were enrolled. The patients received 4Q-TAP blocks in a 10 ml mixture of 2% lidocaine and 0.75% ropivacaine per site (4Q-TAP group, n = 36) or normal saline (control group, n = 33). Oxycodone in the post-anesthesia care unit (PACU) and pethidine or tramadol in the ward were used as rescue analgesics. The primary outcome was less than 3 times of rescue analgesic administration (%) in the ward for 5 postoperative days. Secondary endpoints included oxycodone requirement in PACU, fentanyl doses of IV PCA, morphine milligram equivalent (MME) of total opioid use, hospital stay, and postoperative complications. Results During 5 postoperative days, there was no difference in pain scores and total rescue analgesic administration between two groups. However, the use of oxycodone in PACU (P = 0.011), fentanyl requirement in IV PCA (P = 0.029), and MME/kg of total opioid use (median, 2.35 vs. 3.21 mg/kg, P = 0.009) were significantly smaller in the 4Q-TAP group. Hospital stay and incidence of postoperative morbidity were similar in both groups. Conclusions The 4Q-TAP block enhanced multimodal analgesia and decreased opioid requirements in patients with CRS with HIPEC, but did not change postoperative recovery outcomes.
Collapse
Affiliation(s)
- Jaegyok Song
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Nayoung Choi
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Minji Kang
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Sung Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Dong-wook Kim
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| |
Collapse
|
10
|
Abstract
A new cancer diagnosis is expected to affect approximately 1.9 million people in the United States in 2021. A small percentage of these patients will experience an emergent cancer-related complication. Oncologic emergencies may be encountered in emergency departments or require intensive care management. Patients newly diagnosed with cancer are more likely to present with emergencies related to the underlying malignancies. Oncologic emergencies can have various manifestations, ranging from mechanical obstruction due to tumor growth to metabolic derangements due to abnormal secretions from the tumor. Therefore, early identification and treatment of life-threatening oncologic events is critical. Although there are several different types of oncologic emergencies, this article focuses on metabolic emergencies (tumor lysis syndrome and cytoreductive hyperthermic intraperitoneal chemotherapy) and structural emergencies (increased intracranial pressure and vena cava thrombus). The purpose of this article is to provide acute care clinicians with an overview of selected oncologic emergencies and their evidence-based management.
Collapse
Affiliation(s)
- Ninotchka Brydges
- Ninotchka Brydges is Manager and Advanced Practice Provider, Department of Critical Care Medicine, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030
| | - Garry J Brydges
- Garry J. Brydges is Director, Anesthesia Safety and Quality, Department of Anesthesiology, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
11
|
Wang S, Zhang Q, Chen L, Liu G, Liu PF. Thromboelastography-guided blood transfusion during cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: study protocol for a prospective randomised controlled trial. BMJ Open 2020; 10:e042741. [PMID: 33184089 PMCID: PMC7662436 DOI: 10.1136/bmjopen-2020-042741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a well-established treatment for peritoneal cancer (PC). However, this kind of combination therapy is associated with a high incidence of complications. Moreover, relative studies have indicated that traditional laboratory testing is insufficient to demonstrate the overall haemostatic physiology of CRS/HIPEC. Thromboelastography (TEG), administered by monitoring dynamic changes in haemostasis, has been shown to contribute to reducing transfusion requirements and improving survival. However, there is no evidence to verify whether TEG can be applied to guide transfusion strategies during CRS/HIPEC. Therefore, we aim to investigate whether TEG-guided blood product transfusion (TEG-BT) therapy is superior to traditional blood product transfusion (T-BT) therapy for guiding perioperative blood transfusion treatment and improving the prognosis of patients undergoing CRS/HIPEC. METHODS AND ANALYSIS The TEG-BT versus T-BT study is a single-centre, randomised, blinded outcome assessment clinical trial of 162 patients with PC, aged 18-64 years and undergoing CRS/HIPEC. Participants will be randomly allocated to receive TEG-BT or T-BT. The primary outcome will be the evaluation of perioperative blood transfusion, which refers to the total amount of blood transfusion given from the time patients enter the operating room up to 72 hours postoperatively. The secondary outcomes will include the transfusion volume during surgery, total amount of intraoperative infusion, amount of blood lost during the operation, total blood transfusion between 0 and 72 hours after surgery, lowest haemoglobin level within 72 hours after surgery, intensive care unit duration, overall length of stay, total cost of hospitalisation and adverse events. Data will be analysed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The study protocol has been approved by the Scientific Research Ethics Committee of Beijing Shijitan Hospital Affiliated with Capital Medical University (Approval Number: sjtkyll-lx-2020-3). The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2000028835).
Collapse
Affiliation(s)
- Shaoheng Wang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Qing Zhang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Linfeng Chen
- Department of Blood Transfusion, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Gang Liu
- Department of Peritoneal Cancer Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Peng Fei Liu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
12
|
Pletcher E, Gleeson E, Labow D. Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy. Surg Clin North Am 2020; 100:589-613. [PMID: 32402303 DOI: 10.1016/j.suc.2020.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is an aggressive, potentially curative approach used to treat locoregional disease associated with primary and secondary malignancies of the peritoneum. It involves resection of all macroscopic disease larger than 2.5 mm, followed by instillation of hyperthermic chemotherapy directly into the peritoneum for higher drug exposure to microscopic disease. In select patients with primary peritoneal mesothelioma, pseudomyxoma peritonei, colorectal adenocarcinoma, appendiceal adenocarcinoma, or ovarian cancer, with no extra-abdominal metastasis and limited involvement of the peritoneum, the procedure can be performed to increase overall survival.
Collapse
Affiliation(s)
- Eric Pletcher
- Surgery Department, Mount Sinai West and Morningside, 425 West 59th Street, 7th Floor, New York, NY 10019, USA
| | - Elizabeth Gleeson
- Division of Surgical Oncology, Mount Sinai Hospital, 19 East 98th Street, Suite 7A, New York, NY 10029, USA
| | - Daniel Labow
- Surgery Department, Mount Sinai Hospital, Mount Sinai West and Morningside, 425 West 59th Street, 7th Floor, New York, NY 10019, USA.
| |
Collapse
|
13
|
Elgendy H, Nafady-Hego H, Abd Elmoneim HM, Youssef T, Alzahrani A. Perioperative management and postoperative outcome of patients undergoing cytoreduction surgery with hyperthermic intraperitoneal chemotherapy. Indian J Anaesth 2019; 63:805-813. [PMID: 31649392 PMCID: PMC6798638 DOI: 10.4103/ija.ija_324_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/03/2019] [Accepted: 07/27/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims The existence of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as a multidisciplinary approach for peritoneal cancer gains acceptance in many countries including Saudi Arabia. The aim of our study is to describe the perioperative management of patients who received CRS/HIPEC and to report their outcomes and complications at our tertiary centre. Methods The preoperative characteristics, surgical variables, perioperative management, postoperative course and outcomes of 38 CRS/HIPEC patients were prospectively collected and analysed. Results The mean age of our patients was 52 years, and 23 (60.5%) of them were females. The overall postoperative mortality was 42.1%. Univariate analyses of risk factors for deaths after HIPEC demonstrated that low preoperative (haemoglobin, potassium, calcium and albumin), high (tumour marker (CA19.9), intraoperative transfusion of human plasma protein (HPP), colloids, postoperative activated partial thromboplastin time and bacterial infections were potential risk factors for patient's mortality. Multivariate analysis of those variables demonstrated that low preoperative calcium [hazard ratio (HR) = 0.116; 95% confidence interval (CI) = 0.033-0.407; P = 0.001], high intraoperative HPP transfusion (HR = 1.004; 95% CI = 1.001-1.003; P = 0.012) and presence of postoperative bacterial infection (HR = 5.987; 95% CI = 1.009-35.54; P = 0.049) were independent predictors of patient's death. Seventy morbidities happened after HIPEC; only bacterial infection independently predicted postoperative mortality. Conclusion To improve postoperative outcome of CRS/HIPEC, optimisation of transfusion, temperature, electrolytes and using broader-spectrum prophylaxis to manage postoperative infections should be warranted.
Collapse
Affiliation(s)
- Hamed Elgendy
- Department of Anaesthesia, Faculty of Medicine, Assiut University, Assiut, Egypt.,Department of Anaesthesia, King Abdullah Medical City, Mecca, Saudi Arabia.,Department of Anaesthesia, HAMAD Medical Corporation and Weill Cornell Medicine, Doha, Qatar
| | - Hanaa Nafady-Hego
- Department of Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.,Division of Translational Medicine, Sidra Medical and Research Center, Doha, Qatar
| | - Hanan M Abd Elmoneim
- Department of Pathology, Faculty of Medicine, Minia University, Minia, Egypt.,Department of Pathology, Faculty of Medicine, Umm Alqura University, Mecca, Saudi Arabia
| | - Talha Youssef
- Department of Internal Medicine, Prince Mohammad Bin Abdul-Aziz Hospital, Ministry of National Guard, Al Madinah, Saudi Arabia
| | | |
Collapse
|
14
|
Davis SJ, Byrne KP. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy - perioperative management at Waikato Hospital. Anaesth Intensive Care 2019; 47:100-101. [PMID: 30864484 DOI: 10.1177/0310057x18811993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Simon J Davis
- Department of Anaesthesia and Pain Medicine, Waikato Hospital, Hamilton, New Zealand
| | - Kelly P Byrne
- Department of Anaesthesia and Pain Medicine, Waikato Hospital, Hamilton, New Zealand
| |
Collapse
|
15
|
Teoh DA, Hutton MJH, Else S, Walker A, Lee A, Mack LA. Epidural analgesia? A prospective analysis of perioperative coagulation in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Am J Surg 2019; 217:887-892. [PMID: 30808507 DOI: 10.1016/j.amjsurg.2019.01.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/24/2018] [Accepted: 01/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is beneficial in peritoneal carcinomatosis. Epidurals provide excellent pain relief for laparotomies. Coagulopathy (platelet count <100 × 109/L, INR>1.5 or PTT >45) occurs with CRS and HIPEC, increasing risk for bleeding complications with epidurals. This prospective study characterizes clot kinetics with thromboelastography (TEG) to determine suitability for epidural analgesia. METHODS After Research Ethics approval, thirty consented patients had blood collected. Primary data collected included TEG and conventional coagulation measures (platelets, PTT and INR). Secondary data collected included demographics, disease, surgical, intraoperative factors and complications from epidural placement. RESULTS Of 30 patients analyzed, two had incomplete data. Four developed abnormal coagulation between the second and fifth post-operative day. For all patients, TEG values remained normal. Postoperative INR was elevated until day 3 (all INR < 1.5). 17 patients received epidural analgesia, 3 demonstrated abnormal conventional coagulopathic criteria despite normal TEG. CONCLUSIONS In this study CRS and HIPEC do not contribute to the conventional definition of clinical coagulopathy. Clot kinetics indicate that epidural catheters may be recommended for post-operative analgesia.
Collapse
Affiliation(s)
- Desiree A Teoh
- Department of Anesthesia, University of Calgary, Canada.
| | | | - Scott Else
- Department of Anesthesia, University of Calgary, Canada
| | - Andrew Walker
- Department of Anesthesia, University of Calgary, Canada
| | - Adrienne Lee
- Department of Medicine, Section of Hematology, University of Calgary, Canada
| | - Lloyd A Mack
- Department of Surgery, Division of Surgical Oncology, University of Calgary, Canada
| |
Collapse
|