Hemodynamic goal-directed therapy on Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Authors
Esteve N, Ferrer A, Gómez G, Verd M, Melero C, Mora LC
Research Focus

Cytoreductive Surgery (CS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) results in significant hemodynamic, metabolic and haematological changes1.
Much variation occurs during intraoperative management of these cases2. Controversy has risen on adequate monitoring, fluid therapy, metabolic changes and prevention and treatment of complications.
We present the results of minimally invasive monitoring of Systolic Volume Variation (SVV) and hemodynamic goal-directed therapy.

Methods

Prospective, descriptive study on patients with PC who underwent CS with HIPEC between March 2014 and February 2015. We applied an anaesthesia protocol for monitoring and goals regarding hemodynamics, temperature control, fluid therapy, vasoactive drug use and extubation criteria.

We recorded the data at the beginning of anaesthesia, at various times during CS and HIPEC and along the first three postoperative days.

Results

We included 24 patients. The main intraoperative data were: Intraperitoneal Carcinomatosis 13.7 (±8.1), 96% received epidural analgesia, 92% underwent complete cytoreduction, 42% were transfused perioperatively, median fluid infusion was 8.8 ml/kg/h [ 8.1 - 11.1] and urine output 1.5 ml/kg/h [0.8 - 2,1]. Cardiac index and SVV average intraoperatively were 3.39 L min-1m-2 [3.1 - 3.6] and 11.5% [4.5 - 18.0]. Maximum SVV was at the end of CS and the beginning of HIPEC at 18% and 16.8% respectively.

Average oropharyngeal temperature during HIPEC was 37.4ºC [36.7 - 38.1]. Cardiac index and heart rate were stable through HIPEC. 50% rate of norepinephrine use and 71% of patients were extubated in the operating room. Postoperative morbidity was 25% on severe complications (Clavien-Dindo grade III-IV) and no mortality was recorded.

Conclusion

We found great inter-patient variability on fluid requirements. Monitoring SVV allowed us to predict fluid therapy or vasoactive drug requirement during all stages of surgery and to tailor treatment towards greater hemodynamic stability. The absence of a hyper-dynamic state during HIPEC as seen on other studies, can be accounted on the normovolemia accomplished on our series at the beginning of HIPEC.

References

1.	Raue W et al. Eur Surg Res. 2009; 43:365-72
2.	Corbella D et al. World J Obstet Gynecol 2013; 10; 2: 129-136
3.	Zhang Z et al. J Anesth. 2011; 25:904-16

Hemodynamic goal-directed therapy on cytoreductive surgery with hyperthermic intraperitoneal chemotherapy