Best practice for perioperative management of patients with cytoreductive surgery and HIPEC
C Raspé1, L Flöther1, R Schneider2
1Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Germany.
Insights
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) improves patient outcomes. Anesthesiologists must manage complex fluid shifts and physiological changes for optimal results and patient safety.
Area of Science:
- Oncology
- Anesthesiology
- Intensive Care Medicine
Background:
- Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) significantly improves outcomes and quality of life for various tumor types.
- The increasing adoption of CRS and HIPEC necessitates specialized expertise in anesthesia and intensive care to manage potential high morbidity and mortality.
- Developing standardized clinical pathways is crucial for optimizing treatment in comorbid patients with borderline indications and extensive surgical procedures.
Purpose of the Study:
- To provide a comprehensive update for anesthesiologists and intensivists on managing patients undergoing CRS and HIPEC.
- To highlight critical anesthetic considerations, including fluid management, hemodynamic monitoring, and pain control.
- To emphasize the importance of preoperative, intraoperative, and postoperative strategies for improving patient outcomes.
Main Methods:
- The study reviews current literature and clinical practices related to anesthesia and intensive care for CRS and HIPEC.
- It details the physiological challenges encountered during CRS and HIPEC, such as fluid and protein loss, increased intra-abdominal pressure, and metabolic rate changes.
- Recommendations are provided for advanced hemodynamic monitoring, fluid resuscitation, pain management, and postoperative care.
Main Results:
- Aggressive intravenous fluid substitution is vital to counteract significant fluid loss and maintain adequate volume.
- Thoracic epidural analgesia, non-invasive ventilation, and physiotherapy support effective pain management and facilitate early extubation and fast-track recovery.
- Preoperative preconditioning, postoperative volume optimization, early nutrition, and meticulous coagulation management are essential for improved patient outcomes.
Conclusions:
- Anesthesiologists and intensivists require specialized knowledge and institutional experience to safely and effectively manage CRS and HIPEC procedures.
- Implementing robust clinical pathways and utilizing advanced monitoring are key to preventing adverse events and optimizing care for complex patient populations.
- A multidisciplinary approach focusing on comprehensive perioperative management is critical for maximizing the benefits of CRS and HIPEC.
Abstract:
Due to the significantly improved outcome and quality of life of patients with different tumor entities after cytoreductive surgery (CRS) and HIPEC, there is an increasing number of centers performing CRS and HIPEC procedures. As this procedure is technically challenging with potential high morbidity and mortality, respectively, institutional experience also in the anesthetic and intensive care departments is essential for optimal treatment and prevention of adverse events. Clinical pathways have to be developed to achieve also good results in more comorbid patients with border line indications and extensive surgical procedures. The anesthesiologist has deal with relevant fluid, blood and protein losses, increased intraabdominal pressure, systemic hypo-/hyperthermia, and increased metabolic rate in patients undergoing cytoreductive surgery with HIPEC. It is of utmost importance to maintain or restore an adequate volume by aggressive substitution of intravenous fluids, which counteracts the increased fluid loss and venous capacitance during this procedure. Supplementary thoracic epidural analgesia, non-invasive ventilation, and physiotherapy are recommended to guarantee adequate pain therapy and postoperative extubation as well as fast-track concepts. Advanced hemodynamic monitoring is essential to help the anesthesiologist picking up information about the real-time fluid status of the patient. Preoperative preconditioning is mandatory in patients scheduled for HIPEC surgery and will result in improved outcome. Postoperatively, volume status optimization, early nutritional support, sufficient anticoagulation, and point of care coagulation management are essential. This is an extensive update on all relevant topics for anesthetists and intensivists dealing with CRS and HIPEC.
