Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery. HIPEC combined with cytoreductive surgery (CRS) has developed over time as an effective multimodal treatment option for selected patients with peritoneal surface malignancies
Anaesthesiologist has a crucial role in HIPEC, unique aspects of hipec surgery are hemodynamic fluctuations, hypothermia and induced hyperthermia, fluid shift, coagulopathy, electrolyte and acid-base balance, and potential for chemotherapeutic drug-induced neurotoxicity and nephrotoxicity
CASE REPORT :
A 48-year-old female diagnosed with carcinoma ovary with comorbidities of Asthma, and hypothyroidism on regular medication was planned for HIPEC
PRE-OP PLANNING :
A pre-op assessment was done with detailed history taking, systemic examination, and airway assessment.
Routine investigations were done, cardiac evaluation was done and cardiologist opinion was obtained
Patient was admitted a day before the surgery and was asked to continue her regular medications till the day of surgery
Intra-venous fluids were started night before the surgery
A dose of LMWH was given for DVT prophylaxis
N-acetyl cysteine dose of 600mg given the night before the surgery and same dose at the day of the surgery to prevent acute kidney injury
Plan of anesthesia, risk associated with the procedure, and post operative ventilatory support were clearly explained to the patient and attenders
INTRA – OP :
The patient had adequate nil per oral, nebulization, and pred medications were given and the patient was shifted to the operation theatre
The patient was attached to monitors, hemotherm( can provide hypothermia and hyperthermia) was placed beneath the patient’s table
Epidural catheter was placed for post op analgesia at the level of L1-2
The patient was induced with general anaesthesia drugs , intubated and connected to the ventilator
The central line and artery line were placed. Ryles tube, and temperature probe was inserted
A dose of antibiotic was given and N-acetylcysteine infusion was started based on the weight
Laparotomy and cytoreduction done, and intraperitoneal chemotherapy drugs (oxaliplatin) were given along with 5% Dextrose (for 90 minutes)
Hypermia was induced ( which acts on RNA reductase of ca cells and destroys it)
Base line ABG was taken.
Cold saline were infused, OT temperature were reduced
Inotropes supports were required to maintain MAP of 70-100 mmhg
ABG repeated at mid of the HIPEC, insulin infusion and electrolytes were corrected along with acid base balance.
Post-op
ABG immediate post HIPEC showed ph -7.31, lac-7.4 , hb -9.2
The patient had blood loss of around 600 ml and urine output of 400ml throughout
The patient was shifted to ICU for post-op sedation and ventilation for the next 12 hours
LMWH was started after 8 hours of post-op period for DVT prophylaxis
Inotropes support and insulin infusion were tapered and stopped
ABG at pod 1 (Ph- 7.40, pc02 – 39 , po2 – 70 , lac-1.6 , hb-9.9 )
The patient was conscious and obeying commands, was slowly weaved off from the ventilator, and extubated.
The patient was on nil per oral till pod 2 and was slowly started oral liquids
With hemodynamic stability and orals being tolerated patient was shifted to ward .
DISCUSSION :
PHYSIOLOGICAL CHANGES DURING HIPEC
Many multisystem physiological changes occur during the HIPEC component of the procedure which the anaesthetist must be aware of
Cardiovascular: Increase in heart rate and central venous pressure. No significant changes in blood pressure.
Respiratory: Increase in peak airway pressures. Decrease in PaO2/Fi O2 ratio. Increase in end-tidal CO2 levels.
Renal: Decreased perfusion to kidneys. Metabolic acidosis with increased lactate.
Coagulation: Hyperthermia-associated coagulopathy can see a decrease in platelet count as well as an increase in Prothrombin Time (PT) and International Normalised Ratio (INR)
INTRAOPERATIVE Fluid Management
Fluid replacement is with crystalloid or colloid solutions as well as blood and plasma. The choices between crystalloid and colloid and restrictive or liberal regimes remain the subject of debate. Overall, the anaesthetist should be aware of large fluid shift and should provide a fluid regime that ensures maintenance of systemic and regional perfusion.
8,9 Haemodynamic Management The maintenance of end-organ perfusion is of utmost importance. In response to the rising body temperature associated with the chemotherapeutic agent, the peripheral vasculature dilates. This results in an increase in heart rate in order to maintain cardiac output.
During the closed technique a rise in airway pressures and central venous pressure occurs as a result of increased intra-abdominal pressure. The filling of the abdomen with saline and the chemotherapy has a similar effect to that of a pneumoperitoneum.
Coagulation Management An important factor to consider when anaesthetising someone for CRS and HIPEC is that there can be a significant coagulopathy associated with the procedure. Approximately one-third of patients will develop some sort of coagulopathy requiring transfusion of plasma products.
During the HIPEC stage, coagulation may be impaired due to the hyperthermia, the protein loss, the tumour entity, or the chemotherapeutic toxicity.
CHEMOTHERAPEUTIC CONSIDERATIONS
Depositing the chemotherapy in the peritoneal cavity allows higher doses to be used than would be tolerated systemically. By heating the agent it increases cell permeability and metabolic activity, thus increasing its tumouricidal effects.
In addition to the more common allergic reactions, such as flushing, nausea, and vomiting, consideration should also be given to the direct cardiotoxic effects of the chemotherapy agents. In particular, cisplatin has been associated with prolongation of the QT interval and there have been case reports describing pulseless ventricular tachycardia. It is also important to consider the nephrotoxicity of cisplatin and the need to prevent renal injury. Other agents that are in use, such as mitomycin C and doxorubicin, are associated with myelotoxicity and neurotoxicity.
Dr Velmurgan D
Department Of Anaesthesia
Kauvery Hospital, Chennai
Dr A Varun
DnB Anesthesia Resident
Department Of Anaesthesia
Kauvery Hospital, Chennai