Anesthesia considerations during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Standardised Critical Care Strategies Improve Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in an Indian Peritoneal Malignancy Centre

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major undertaking with profound peri-operative metabolic and haemodynamic alterations. It requires standardised protocols for immediate postoperative intensive care management to improve patient-related outcomes. A retrospective analysis of a prospectively maintained data-base of 244 patients who underwent CRS and HIPEC between June 2017 and July 2022 in our institute was done. Based on the audit, six strategies were implemented, namely, (1) dynamic multiparameter-based IVF therapy to aggressively correct the hyperlactatemia, (2) initiation of IV 20% human albumin infusion from POD-0, (3) correction of serum iCa2+ levels, (4) initiation of diuresis from POD-1, (5) prophylactic use of HFNO immediately post-extubation and (6) serum procalcitonin level-based empiric escalation of IV antibiotics. Patients were divided into two cohorts, pre-protocol group of 145 patients (from June 2017 to December 2020) and post-protocol group comprising of 99 patients (from January 2021 to July 2022), and were analysed for compliance and patient-related outcomes. Implementation of these strategies improved the patient-related outcomes among the two cohorts with significant reduction of Clavien-Dindo grade III/IV complications and improvement in failure to rescue (FTR) index (p < 0.05). There was highly significant reduction in median ICU and hospital stay among the two cohorts (p < 0.001). The formulated protocols of management strategies especially multiparameter-based dynamic fluid therapy, planned diuresis and prophylactic HFNO have improved the outcomes in our patients undergoing CRS and HIPEC.

Intraoperative metabolic changes associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) causes considerable hemodynamic, respiratory, and metabolic changes during the perioperative period.

OBJECTIVES

To evaluate metabolic changes associated with this procedure. Understanding perioperative factors and their association with morbidity may improve the perioperative management of patients undergoing this treatment.

METHODS

A retrospective review of a prospectively maintained database was performed. All consecutive unselected patients who underwent CRS plus HIPEC between January 2018 and December 2020 (n = 219) were included.

RESULTS

The mean age was 58 ± 11.7 years and 167 (76.3%) were female. The most frequent histology diagnosis was serous ovarian carcinoma 49.3% (n = 108) and colon carcinoma 36.1% (n = 79). Mean peritoneal cancer index was 14.07 ± 10.47. There were significant variations in pH, lactic acid, sodium, potassium, glycemia, bicarbonate, excess bases, and temperature (p < 0.05) between the pre-HIPEC and post-HIPEC periods. The closed HIPEC technique resulted in higher levels of temperature than the open technique (p < 0.05). Age, potassium level post-HIPEC potassium level, and pre-HIPEC glycemia were identified as prognostic factors for morbidity in multivariate analysis.

CONCLUSION

The administration of HIPEC after CRS causes significant changes in internal homeostasis. Although the closed technique causes a greater increase in temperature, it is not related to higher morbidity rates. The patient's age, post-HIPEC potassium level, and pre-HIPEC glycemia are predictive factors for morbidity.

Four different methods of measuring cardiac index during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are high-risk extensive abdominal surgery. During high-risk surgery, less invasive methods for cardiac index (CI) measurement have been widely used in operating theater. We investigated the accuracy of CI derived from different methods (FroTrac, ProAQT, ClearSight, and arterial pressure waveform analysis [APWA], from PICCO) and compared them to transpulmonary thermodilution (TPTD) during CRS and HIPEC in the operative room and intensive care unit (ICU).

METHODS

Twenty-five patients scheduled for CRS-HIPEC were enrolled. During nine predefined time-points, simultaneous hemodynamic measurements were performed in the operating room and ICU. Absolute and relative changes of CI were analyzed using a Bland-Altman plot, four-quadrant plot, and interchangeability.

RESULTS

The mean bias was -0.1 L/min/m2 for ClearSight, ProAQT, and APWA and was -0.2 L/min/m2 for FloTrac compared with TPTD. All devices had large limits of agreement (LoA). The percentage of errors and interchangeabilities for ClearSight, FloTrac, ProAQT, and APWA were 50%, 50%, 54%, 36% and 36%, 47%, 40%, 72%, respectively. Trending capabilities expressed as concordance using clinically significant CI changes were -7º ± 39º, -19º ± 38º, -13º ± 41º, and -15º ± 39º. Interchangeability in trending showed low percentages of interchangeable and gray zone data pairs for all devices.

CONCLUSIONS

During CRS-HIPEC, ClearSight, FloTrac and ProAQT systems were not able to reliably measure CI compared to TPTD. Reproducibility of changes over time using concordance, angular bias, radial LoA, and interchangeability in trending of all devices was unsatisfactory.

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

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

Laparoscopic cytoreductive surgery and HIPEC is effective regarding peritoneum tissue paclitaxel distribution

BACKGROUND

In some patients with peritoneal carcinomatosis, we could perform the cytoreductive surgery and the HIPEC procedure by a complete laparoscopic approach to avoid morbidity. We consider that using laparoscopic approach for performing peritoneal carcinomatosis cytoreductive surgery and HIPEC with closed CO₂ recirculation technique is possible and safe, with equal efficacy to conventional methods and hemodynamic complications.

OBJECTIVE

Monitoring the effectiveness of the drug distribution in a laparoscopic ctoreductive and HIPEC surgery group with CO₂ recirculation respect to a closed and open HIPEC group METHODS: Porcine model that included fifteen mini-pigs. Five pigs were operated with laparoscopic approach performing a pelvic and retroperitoneal lymphadenectomy. They later received a total laparoscopic closed HIPEC with CO₂ recirculation (G1). Group 2 (G2): five pigs operated by an open cytoreductive surgery and closed HIPEC technique. Group 3 (G3): five animals in which an open cytoreductive surgery and an open HIPEC technique was performed. Blood and peritoneal determinations were realized after recirculation of the drug, at 60 min using chromatographic analysis.

RESULTS

G1-G2: phrenic right peritoneum, p: 0.46. Phrenic left peritoneum, p: 0.46. Pelvic peritoneum, p: 0.17. Serum paclitaxel: p: 0.01. G1-G3: phrenic right peritoneum, p: 0.34. Phrenic left peritoneum, p: 0.34. Pelvic peritoneum, p: 0.17. Serum paclitaxel G1-G3, p: 0.02.

CONCLUSIONS

A total laparoscopic approach for ctoreductive surgery and closed HIPEC with CO₂ recirculation may be safe and feasible. In our experimental model there was no significant difference in tissue drug distribution respect the conventional techniques and there was a less toxicity because the serum drug concentration was significantly lower with laparoscopic approach respect the other groups.

Changes in Hepatic Blood Flow and Liver Function during Closed Abdominal Hyperthermic Intraperitoneal Chemotherapy following Cytoreduction Surgery

BACKGROUND

The increase in intra-abdominal pressure (IAP) during closed abdominal hyperthermic intraperitoneal chemotherapy (HIPEC) leads to major haemodynamic changes and potential organ dysfunction. We investigated these effects on hepatic blood flow (HBF) and liver function in patients undergoing HIPEC following cytoreductive surgery and fluid management guided by dynamic preload indices.

METHODS

In this prospective observational clinical study including 15 consecutive patients, we evaluated HBF by transesophageal echocardiography and liver function by determination of the indocyanine green plasma disappearance rate (ICG-PDR). Friedman's two-way analysis of variance by ranks and Wilcoxon signed-rank test were performed for statistical analysis.

RESULTS

During HIPEC, HBF was markedly reduced, resulting in the loss of any pulsatile Doppler flow signal in all but one patient. The ICG-PDR, expressed as median (interquartile 25-75), decreased from 23 (20-30) %/min to 18 (12.5-19) %/min (p < 0.001). Despite a generous crystalloid infusion rate (27 (22-35) ml/kg/h), cardiac index decreased during the increased IAP period, inferior vena cava diameter decreased, stroke volume variation and pulse pressure variation increased, lung compliance dropped, and there was an augmentation in plateau pressure. All changes were significant (p < 0.001) and reversed to baseline values post HIPEC.

CONCLUSION

Despite optimizing intravenous fluids during closed abdominal HIPEC, we observed a marked decrease in HBF and liver function. Both effects were transient and limited to the period of HIPEC but could influence the choice between closed or open abdominal cavity procedure for HIPEC and should be considered in similar clinical situations of increased IAP.

The Global End-Diastolic Volume (GEDV) Could Be More Appropiate to Fluid Management Than Central Venous Pressure (CVP) During Closed Hyperthermic Intrabdominal Chemotherapy with CO2 Circulation

BACKGROUND

Closed hyperthermic intraperitoneal chemotherapy (HIPEC) may increase abdominal pressure and effects of hemodynamic changes due to maintenance hyperthermia. Our aim was to analyze the safety and effectiveness of our closed technique with CO₂ circulation in management fluid status and hemodynamic parameters by means of cardiac preload control measured by Global End Diastolic Values (GEDV) and a gas exchanger.

MATERIAL AND METHODS

A Pilot Clinical Study that included 18 advanced ovarian cancer patients undergoing citoreductive surgery and HIPEC. We used a closed-perfusion system (PRS Combat®) that includes CO₂ circulation and a gas exchanger. Transpulmonary thermodilutions and hemodynamic measurements (PiCCO₂®) were performed after citoreductive surgery (Pre-HIPEC); At half time of the HIPEC (Intra-HIPEC); After HIPEC (Post-HIPEC).

RESULTS

No significant hemodynamic measurements changes in the three thermodilutions values of Cardiac Index (CI) (p = 0.227), Global End Diastolic Values (GEVD) (p = 0.966), Stroke Volume Variation (SVV) (p = 0,884) and Systemic Vascular Resistance Index (SVRI) (p = 0.082). No correlation between central venous pressure (CVP) and GEDV (Pre-HIPEC: r = 0.164, p = 0.211; Intra-HIPEC: r = 0.015, p = 0.900; Post-HIPEC: r = 0.018, p = 0.890). There was better correlation between GEDV and CI (Pre-HIPEC: r = 0.432, p = 0.071; Intra-HIPEC: r = 0.418, p = 0.074; Post-HIPEC: r = 0.411, p = 0.080).

CONCLUSIONS

Closed intrabdominal chemotherapy with CO₂ circulation model may be a safe model for HIPEC by means of a gas exchanger. GEDV and its changes significantly correlated to CI, and not observed for CVP. GEDV values may be more appropriate for monitoring cardiac preload, blood loss limitation and to predict changes in intravascular volume status during intraperitoneal chemotherapy.

Preoperative Preparation and Patient Selection for Cytoreductive Surgery and HIPEC

Peritoneal dissemination is a significant variable affecting long term survival of abdominal cancer patients. A generally accepted clinical point of view is that peritoneal dissemination is tantamount to distant organ metastases. This implies it to be a terminal condition. Current practice dictates that if peritoneal dissemination is observed intraoperatively, the curative therapeutic options are deferred and comprehensive systemic chemotherapy remains the only option with a dismal prognosis. The past few years have generated lot of interest in management of peritoneal carcinomatosis. Prof Paul Sugarbaker has researched, validated and fine-tuned the concept of cytoreductive surgery with peritonectomy procedure (Sugarbaker technique) and perioperative chemotherapy as HIPEC & EPIC. Recognition of a HIPEC centre is based on an infrastructure equipped with basic knowledge of the tumor biology, oncosurgical techniques, technical knowhow for HIPEC administration, intensive care unit etc. There are some aspects which need to be accorded special consideration. Comprehensive therapy of Cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is initiated with exploration and cytoreductive surgery and includes visceral resections and peritonectomy procedure when achieved optimally results in complete, visible resection of all cancer within the abdomen and pelvis. Subsequent to CRS, HIPEC forms an integral part of the surgical procedure. This approach involves conceptual changes in both the route and timing of chemotherapy administration. Patient selection is of utmost importance. The greatest impediment to lasting benefits from intraperitoneal chemotherapy remains an improper patient selection. Currently, there are four important clinical assessments of peritoneal metastasis that need to be used to select patients ie; histopathological type of tumour, radiological distribution of disease, peritoneal cancer index and completeness of cytoreduction. Patients undergoing HIPEC surgery face the usual physiological insults of a major surgery in addition to the thermal stress secondary to intraperitoneal administration of heated chemotherapy agent. A team approach of everyone involved in care of these patients is known to improve patient outcomes. It has also been observed that with the necessary preoperative & perioperative steps, the morbidity and mortality for this treatment can be brought down as comparable to any other major abdominal surgeries.

Organ dysfunction in critically ill cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

The aim of the present study was to observe the incidence of organ dysfunction and the intensive care unit (ICU) outcomes of critically ill cancer patients during the cytoreductive surgery with hyperthermic intraperitoneal chemotherapy post-operative period. The present study included 25 critically ill cancer patients admitted to the ICU of the National Cancer Institute (Mexico City, Mexico) between January 2007 and February 2013. The incidence of organ dysfunction was 68% and patients exhibiting ≤1 organ system dysfunction during ICU admittance remained in hospital for a significantly shorter period compared with patients who exhibited ≥2 organ system dysfunctions (12.4±10.7 vs. 24.1±12.8 days; P=0.025). Therefore, the present study demonstrated that a high incidence of organ dysfunction was associated with a longer ICU hospital stay.

Strategies for the management and avoidance of hypothermia in the perioperative environment

This Open Learning Zone article outlines the necessity of monitoring temperature for patients undergoing surgical procedures with either general or local anaesthesia. An overview of the physiology of heat production and loss in the human body, and temperature as thermal measurement is given.

Cytoreduction with hyperthermic intraperitoneal chemotherapy: An anaesthetic challenge

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy plays a considerable role as a treatment modality in surgical oncology in western countries. The advantage of this procedure is that the heated chemotherapeutic agent is circulated in the abdominal cavity and achieves high peritoneal concentration with limited systemic absorption. This procedure is complex not only to the surgical team, but also to the anaesthetist because apart from managing the usual physiologic changes associated with major surgery, one should also be prepared to manage the physiologic changes during the hyperthermic phase. Here, we present our experience with our first case.