Introduction: The hyperthermic isolated limb perfusion (HILP) main indication is intractable and/or recurrent melanoma metastases of the limb. The isolated limb is exposed to high dosage of citotoxic agents; simultaneously efforts are made to avoid systemic toxicity. The intraoperative management of these patients is a challenge to the anaesthesiologist and it is not clearly established in the literature yet. The objective of this study is to describe our anesthetic practice.

Methods: Descriptive retrospective study, data collected from clinical records of all patients submitted to lower limb HILP between January 2015 and November 2017. Variables analyzed: demographic characteristics, anesthetic technique, advanced hemodynamic monitoring, chemotherapy, perioperative fluid imbalance, intraoperative vasopressor needs; mean surgery duration, type of postoperative vigilance, mean internment duration. Descriptive analysis: Microsoft Excel®.

Results: We evaluated 40 patients. Mean age: 70 years old, 78% females, 53% ASA II and 47% ASA III. Balanced general anaesthesia (BGA) was chosen in 80% of the patients and Combined anaesthesia (BGA + Quadratus lumborum type 1 block) in 20%. Anaesthesia maintenance with sevoflurane or desflurane (50/50%), and fentanyl according to patient needs (mean dose: 325 ug). Chemotherapy: Melphalan and TNF-α association in 88% of the patients, and Melphalan alone in 12%. Hemodynamic monitoring: invasive arterial pressure in all patients, VIGILEO in 58% and Central venous pressure in 38%. Crystalloids mean: 3240ml. Colloids mean: 88ml. Urinary output: 772ml. Intraoperative mean blood loss: 1134ml. Blood transfusion required in all but one patient, mean erythrocyte units transfunded: 3. Intraoperative vasopressors needs: in 38% of the patients (Ephedrine 28%, Phenylephrine 8%, Dopamine 2%). Surgery mean duration: 383 minutes. Post operative vigilance: 10% intermediate care unit and 90% intensive care unit. Internment mean duration: 16 days. 

Discussion: HILP is a complex surgery, which demands team work between anaesthetists, surgeon, nurses and perfusionist in order to prevent complications associated to this procedure. Fluid exchange and cytokine release are associated with important hemodynamic variations, which makes hemodynamic monitoring a primary concern in the anesthetic management of these patients. 

Bibliography: BMC Anesthesiology 2013, 13:15.



06 / Perioperative anaesthethic management of patients undergoing isolated lower limb perfusion