BACKGROUND AND GOAL OF STUDY
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with intense hemodynamic and metabolic changes related with the thermal stress induced by intraperitoneal instillation of heated chemotherapy. Data on the cardiovascular conditions, intravascular volume status and optimal fluid resuscitation during HIPEC are limited. We conducted a prospective observational trial to assess the detailed amounts of volume given and cardiovascular function during the CRS-HIPEC.
MATERIAL AND METHODS
After IRB approval, consecutive patients were enrolled. The intraoperative volume therapy and hemodynamic management were guided by invasive transpulmonary thermodilution technique (Volume-View®) and were based on cardiac index (CI), stroke volume index (SVI), mean arterial pressure (MAP) and stroke volume variation (SVV). During the debulking phase and after the chemotherapy administration, a restrictive regime was tried; during HIPEC, a liberal cool fluid therapy was used to increase urine output and to control hyperthermia. Statistical analysis was performed with SPSS version 20 (t-student paired test and ANOVA with repeated measures). 
RESULTS
38 ASA I-III patients (57±11 years) with a peritoneal carcinomatosis index (PCI) 15±10 were studied. The duration of the procedure was 11±2h and the HIPEC time was 30, 60 and 90 min in 18%, 74% and 8% respectively. A combined general/epidural anesthesia was used in 95% of patients. Large amounts of fluids were administered throughout the procedure (median 5,450mL; range 4100-5950mL). There was a significant difference in fluids administered during HIPEC: 1,500mL/h (1,025-1,683) vs. 376mL/h (333-427) pre+post HIPEC period (p=0,0001). A hyperdynamic status was observed during HIPEC: a 49% increment in CI (p=0.0001); a 38% decrease in SVRI (p=0.0001) and a 15% decrease in MAP (p=0.014) with respect to baseline. Diuresis during HIPEC was 8mL/kg/h (7.2-14) and maximum temperature was 38.8±0.86ºC. Transfusion and norepinephrine were especially required in patients with higher PCI: 23 vs. 13 (p=0.037) and 22 vs. 12,7 (p=0.02) respectively.
CONCLUSIONS
CRS-HIPEC is associated with an intense hemodynamic alteration and an aggressive fluid requirement. The implementation of invasive monitoring permits real time status information that is of utmost importance to maintain fluid homeostasis during this complex surgery. 

02 / Hemodynamic optimization with trans-pulmonary thermodilution and pulse contour analysis during hyperthermic intraperitoneal chemotherapy. A prospective observational study