Anesthesia for peritonectomy with hyperthermic intraoperative peritoneal chemotherapy. Case report

Pseudomyxoma peritonei is a rare condition related to epithelial neoplasia of the appendix and ovaries. Surgical cytoreduction, peritonectomy, and hyperthermic intraoperative peritoneal chemotherapy (HIPEC) is the treatment of choice. Maintenance of normovolemia, normothermia, postoperative pain management and coagulation status are all responsibility of the anesthesiologist. The objective of this report was to describe a case of peritonectomy with HIPEC.

This is a 37 year-old female, ASA I, with a history of appendectomy 3 months ago with an anatomopathological report of mucinous cystoadenoma. After review of the pathological sample, a pseudomyxoma peritonei was diagnosed with indication of peritonectomy with HIPEC. An epidural catheter (T11-T12) was placed and a test-dose, as well as morphine, was administered. Anesthesia was induced with remifentanil, 0.4 μg.kg⁻¹.min⁻¹, propofol, and rocuronium, besides rapid-sequence orotracheal intubation. Remifentanil, sevoflurane, and rocuronium were used for anesthesia maintenance according to the TOF. Ropivacaine 50mg, and fentanyl 10 μg. in 10 mL were administered through the epidural catheter 10 minutes before incision. During the surgery, CVP, SpO₂, FeCO₂, temperature, heart rate, MAP, and urine output maintained stable levels within normal limits, including during HIPEC. Reduction of the hematocrit and SvO₂, increased PT, and thrombocytopenia were corrected by administering blood products. After 13 hours of surgery, the patient was admitted to the ICU under controlled ventilation. She was extubated on the 1(st) postoperative day, being discharged from the hospital on the 17(th) day of hospitalization.

Surgical cytoreduction and peritonectomy with HIPEC goes back to the decade of 1990 with several studies showing a significant increase in survival. Due to the complexity of the procedure and large surgery the vigilance of the anesthesiologist is fundamental for maintenance of clinical and laboratorial parameters, and recognition and treatment of any changes.