Impact of Intraoperative Anesthetic and Fluid Management on 30-day Postoperative Outcomes in a Newly Established Surgical Peritoneal Surface Malignancy Program

Abstract

Background: Anesthetic and fluid management during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may influence 30-day postoperative outcomes. We investigated intraoperative management differences and their relation to outcomes in all consecutive patients undergoing HIPEC and CRS following the first 2 years after initiation of this surgical oncology program in a single center. Methods:Following IRB approval we retrospectively recorded demographics, intraoperative anesthetic and fluid management and 30-day postoperative cardiopulmonary, renal, infectious, neurologic, and surgical complications, mortality and length-of-stay in patients undergoing CRS and HIPEC. The Chi-square, Fisher's exact and Wilcoxon two-sample tests were used for statistics. A p < 0.05 was significant. Results:We identified 34 patients with a mean age of 53.9 ± 11.5 years. Postoperative complications occurred in 14 patients (41%), twelve of whom (35%) had pulmonary adverse events. Patients with complications were significantly older (p=0.04) and were significantly longer hospitalized (p=0.00). Neither primary malignancy type nor intraoperative fluid replacement differed between groups. Patients with complications had mild preoperative anemia (p=0.052). Conclusions:In this initial single center experience with CRS and HIPEC, patients experienced liberal intraoperative fluid replacement, a high postoperative complication rate, but no 30-day mortality. Patients with postoperative complications were significantly older, while intraoperative anesthetic and fluid management were not different between groups. Preoperative anemia in patients developing postoperative complications deserves prospective study. A steep learning curve in patient selecion and intraoperative management was observed.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

“…The recommended targets for urine output during various phases are up to 0.5 mL/kg/h during CRS, 2–4 mL/kg/h during the HIPEC phase and 1–2 mL/kg/h post-HIPEC phase. [134647] However, these thresholds are debatable in the context of individualised fluid therapy.…”

“…Fluid overload has been found to be associated with an increased morbidity. [4647] Restrictive fluid regimens have demonstrated decreased perioperative mortality in other major surgical procedures. [626364] However, restricted fluid therapy can cause suboptimal tissue and renal perfusion in the face of extreme haemodynamic changes that occur during the phases of CRS-HIPEC.…”

Cytoreductive onco-surgery with combined hyperthermic intraperitoneal chemotherapy and hyperthermic intrathoracic chemotherapy: Perioperative challenges

“…Both hypovolemia and hypervolemia can be detrimental. [ 9 10 ] Urine output measurement could be a noninvasive, reliable surrogate marker of renal perfusion and goal of urine output of 0.5 ml/kg/h during cytoreductive phase; 4 ml/kg/h during HIPEC and 1–2 ml/kg/h in post-HIPEC phase are required. [ 11 ] ABG measurements may guide fluid therapy by lactate levels as well as provide information about acid–base and electrolyte status.…”

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Fluid and temperature remain the culprit!

“…In a retrospective analysis of 34 patients undergoing CRS and HIPEC, authors reported that, in patients with liberal intraoperative fluid replacement, a high postoperative complication rate, especially pulmonary, was observed. [ 14 ] In a recent study on 133 patients, intraoperative fluid rate was significantly associated with increased morbidity. [ 15 ] The patients receiving >15.7 mL/kg/h of intraoperative fluids experienced a 43% increase in complications as compared to those receiving less than this amount.…”

“…Meticulous fluid management as per goal-directed therapy appears to answer these issues. [ 13 14 ] The non-invasive cardiac output monitoring and urine output appear to be an acceptable monitoring tool in such surgeries. [ 17 ] The fluid management was guided by non-invasive continuous cardiac output monitoring with FloTrac in patients with high tumour load and patient having persistent haemodynamic perturbations in the study being published.…”