Anesthesiological management during isolated liver perfusion

The treatment of irresectable hepatic metastases is limited by the systemic toxicity of anticancer agents. Isolated hyperthermic liver perfusion (IHLP) with anticancer agents is a new therapy for irresectable liver tumors. The risks of this therapy lie in the extended operation, the anhepatic phase and the possibility of liver damage due to the anticancer drug and hyperthermia. Experience of this method is rare, and the side effects are not well known. To estimate the individual risk of patients before isolated liver perfusion an extended evaluation of the preoperative conditions is usual. Titration of all anesthetic agents is advisable to prevent cardiovascular changes and to avoid an extended recovery time after therapy. Based on our experience with IHLP in ten patients, we prefer coinduction with midazolam and thiopentone. After intubation, intermittent positive pressure ventilation with positive end-expiratory pressure is instituted with 30% oxygen in air. Pancuronium bromide is used to provide muscular paralysis, and isoflurane is administered throughout the procedure. Anesthesia is supplemented by fentanyl and midazolam. Invasive hemodynamic monitors may be placed after induction of anesthesia. Our first results with IHLP indicate that, under the conditions of elevated monitoring, complete isolation of the liver, a good wash-out and a safe anesthesiological management, no major disturbances must be expected during the therapy. The patients are more compromised by the therapy during the following days. Low diastolic blood pressure and loss of resistance after perfusion were the first signs of a toxic reaction.