Morbidity in cytoreductive surgery plus HIPEC poses challenge for anaesthetists
Perioperative management of cytoreductive surgery (CRS) along with hyperthermic intraperitoneal chemotherapy (HIPEC), a major surgery that is the treatment of choice for selected patients with peritoneal carcinomatosis, remains a serious concern for anaesthetists due to its significant morbidity, according to a Singapore study.
“Even though many patients who present for this surgery are relatively young and without significant comorbidity, the extensive procedure often results in multisystemic derangements that include the cardiorespiratory system, fluid and acid-base balance as well as body temperature,” researchers said.
In this study, the authors reviewed CRS and HIPEC procedures at a centre from January 1997 to December 2012, with a focus on perioperative events and anaesthetic implications.
A total of 111 patients (mean age 51.7 years; 84.1 percent women) underwent 113 CRS and HIPEC procedures (mean duration of surgery, 9 hours 10 minutes). The origin of most tumours were ovarian or colorectal, and the mean peritoneal cancer index (PCI) score was 14.3. Estimated blood loss was at a mean of 1,481 mL. Mean total intravenous fluids and blood products administered was 8,498 mL. [Singapore Med J 2017;58:488-496]
“In our patient group, the range of blood loss was wide and corresponded with the extent of surgery… Blood loss can be sudden and torrential, particularly during the cytoreductive phase and stripping of the liver capsule. Drainage of ascites, blood loss and evaporative loss from raw peritoneal surfaces can dramatically deplete intravascular volume,” researchers said.
“Therefore, appropriate fluid or blood products should be administered in a timely manner, as guided by clinical estimates of blood loss, urine output, haemodynamics, and haemoglobin and acid-base measurements,” they added.
Of the patients, 79.5 percent were transferred to the intensive care unit (ICU) postoperatively as 75.2 percent of the procedures required interval extubation. Those with lower PCI scores were more likely to be extubated immediately after surgery (p<0.05). In addition, 80 percent of patients had coagulopathy postoperatively, which was associated with longer HIPEC duration (p<0.05).
ICU and hospital stays had median lengths of 2 and 14 days, respectively. Longer duration of surgery was significantly associated with longer hospitalization. The common causes of prolonged hospital stay were as follows: nosocomial pneumonia, pleural effusions, respiratory failure, sepsis, surgical complications (such as anastomotic or wound dehiscence) and intra-abdominal infections.
“There is emerging evidence that goal-directed therapy can reduce perioperative mortality and morbidity in patients undergoing high-risk surgeries. 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 vs 8.3 L) for patients undergoing CRS and HIPEC,” researchers said. [Crit Care 2013;17:209; J Gastrointest Surg 2015;19:722-9]
“As a result, there was an 18-percent reduction in risk of abdominal complications, such as infection and anastomotic dehiscence, as well as 10-day reduction in length of hospitalization,” they added. [J Gastrointest Surg 2015;19:722-9]
According to researchers, the current study is the largest series that specifically looked at the CRS and HIPEC technique in terms of its anaesthetic management. The specific perioperative anaesthetic concerns for peritonectomy highlighted in this study were related to blood loss and fluid management, analgesia, temperature, antibiotics, airway pressure and acid-base changes, criteria for extubation, and recovery.
“We look forward to the development of an optimal anaesthetic technique in conjunction with evidence-based medicine,” researchers said.