Anesthetic management of Hyperthermic Intra Peritoneal Ch

1. HIPEC
MAGDY GHATTAS
Consultant of anesthesia and intensive care
Ismailia Oncology Teaching Hospital

2. Presentation includes short notes about
• Physiological changes during HIPEC
• Patient selection criteria for HIPEC and
Cytoreductive Surgery (CRS)
• Preoperative concerns
• Severe fluid shift
• HIPEC and electrolyte balance
• Hemodynamic management
• Control of body temperature
• Postoperative complications
• Postoperative/critical care management
• Conclusion

3. PHYSIOLOGICAL CHANGES DURING
HIPEC
• Cardiovascular: Increase in heart rate and
central venous pressure. No significant
changes in blood pressure.
• Respiratory: Increase in peak airway pressures
up to 30 mmHg.
Decrease in tissue oxygenation.
Increase in end-tidal CO2 levels.

4. PHYSIOLOGICAL CHANGES DURING
HIPEC
• Renal: Decreased perfusion to the kidneys.
Metabolic acidosis with increased lactate.
• Coagulation: Hyperthermia-associated
coagulopathy with a decrease in platelet
count (Thrombocytopenia)
as well as an increase in Prothrombin Time (PT)
and International Normalized Ratio (INR).
(Coagulopathy is corrected on the 5th PO day).

5. Selection Criteria for HIPEC and
Cyto Reductive Surgery
• Medical optimization with no active cardiac or
respiratory conditions.
• Absence of extra abdominal disease, extensive
hepatic metastases, and significant retroperitoneal
disease.
• Age less than 70 years , however not
absolutely indicated.
• Peritoneal disease that is amenable to complete or
near complete resection.

6. • It is imperative to perform a detailed
preoperative assessment to avoid ORGAN
FAILURE that may occur in some patients.
• Operative risk assessment for comorbidities
like diabetes, hypertension and
heart disease.
• Assessment of pulmonary system.

7. Preoperative Concerns
• AGAIN Thorough assessment of the
patient’s cardiac and pulmonary systems
is essential to assess their ability to
respond to the physiological challenges
faced intraoperatively .

8. PREOPERATIVE WORKUP
• Most patients for elective major abdominal surgery
invariably undergo adequate preoperative assessment
and evaluation.
• Echocardiography and dynamic cardiac assessments
• Full blood count
• Coagulation studies
• Electrolytes, urea and creatinine levels
• Review the nutritional status of the patient and to
measure a preoperative albumin level
• Glomerular filtration rate to identify patients at risk of
an acute kidney injury associated with the HIPEC

9. PREOPERATIVE WORKUP
Preoperative SERUM ALBUMIN deserves
a special mentioning .
• It reflects the nutritional status of the patient.
• Albumin levels strongly predicts length of hospital
stay and overall survival.
• Malnutrition may be present in >50% of patients with
ovarian cancer and advanced colorectal cancer with
peritoneal metastasis.
• Preoperative correction of anemia and
hypoalbuminemia is preferable.

10. VENOUS THROMBO-
EMBOLISM PROPHYLAXIS
Mechanical pneumatic
compression stockings
should be applied

11. OF HIPEC and CRS
PERIOPERATIVE CONCERNS
OF HIPEC and CRS
Perioperative management is complex
and is associated with :
• Massive fluid shift
• Blood loss
• Temperature imbalance
• Hemodynamic alterations
And
• Renal toxicity of chemotherapeutic drugs

12. Chemotherapeutics used during hyperthermic
intraperitoneal chemotherapy and possible
chemotherapeutic-specific adverse effects
Mitomycin C: Nephrotoxicity, pulmotoxicity
Cisplatin Peripheral neuropathia, myelotoxicity
Cisplatin : Peripheral neuropathia, myelotoxicity
Doxorubicin : Cardiotoxicity (arrhythmia,
cardiomyopathy), myelotoxicity
Oxyliplatin : Neurotoxicity (laryngeal/pharyngeal
dysesthesia)
Irinotecan : Myelotoxicity

13. MASSIVE FLUID SHIFT
• Significant blood loss associated with the
major debulking surgery.
• Evaporative losses related to the
open abdomen.
• Ascites drainage of protein‐rich fluid.
• HIPEC causes peritoneal inflammation
that can cause perioperative fluid loss.

14. MASSIVE FLUID SHIFT
• Intraoperative fluid losses may be as high
as 12-20 ml/kg/hour depending on the
degree of debulking i.e. 1800 ml/hour.
• Large amount of fluid shift occurs during
cytoreductive phase due to large raw surface
produced by peritonectomy, ascitic drainage
and significant blood loss during this procedure .

15. MASSIVE FLUID SHIFT
• Anesthesiologists need to manage intravenous
fluid therapy, blood transfusion and electrolyte
balance to maintain optimal end-organ
perfusion and prevent renal injury.
• Patients with poor cardiac reserve may not
tolerate a high volume of intravenous fluid and
may require vasopressors and inotropes to be
used carefully .

16. MASSIVE FLUID SHIFT
• Fluid replacement is with crystalloid or colloid
solutions as well as blood and plasma .
• Up to NINE LITERS of blood loss has been
reported during Cytoreduction Surgery (CRS)
and HIPEC due to surgical reasons and
coagulation abnormalities.

17. RENAL PROTECTION
• The best way to preserve renal function is to
maintain NORMOVOLEMIA and
ADEQUATE URINARY OUTPUT
(1mL/kg/h).
NO diuretics or dopamine is recommended.

18. HIPEC AND ELECTROLYTE
BALANCE
• Chemotherapeutic agents (especially if dissolved
in DW5%) may lead to:
• Dilutional Hyponatremia ( serum sodium ) ( ? Mechanism)
• Lactic acidosis mainly due to increased
glucose metabolism and anaerobic metabolism.
• Hypomagnesaemia which leads to cardiac
arrhythmias .
• Electrolyte disturbances like calcium, potassium
and magnesium should be replaced if required.

19. HIPEC AND ELECTROLYTE
BALANCE
Frequent ABG,
and electrolytes
(sodium,
potassium,
calcium and
magnesium)
are desired to
be measured
calcium and
magnesium)
are desired to
be measured
to detect and
manage the
abnormalities
early.
to detect and
manage the
abnormalities
early.

20. Hemodynamic Management
• Hyperthermia during HIPEC leads to peripheral
vasodilatation and reduction in peripheral
vascular resistance and mean arterial pressure .
• There is an increase in heart rate in order to
maintain cardiac output .
• An arterial line, a central venous catheter and
a urinary catheter are useful for monitoring the
hemodynamic status of the patient in real time .

21. CONTROL OF BODY
TEMPERATURE
• CRS combined with HIPEC can be associated
with both hypothermia and hyperthermia.
• Hypothermia occurs during CRS and increases
the risk of blood loss and surgical wound
infections.
• Hyperthermia: The carrier solution for HIPEC
is heated to 42C-43C and body temperature
may rise to up to 40.5 C. (? Effects on abdominal organs)

22. CONTROL OF BODY
TEMPERATURE
• Hyperthermia increases the systemic oxygen
demand, and may lead to an increased
metabolic demand levels and a concomitant
metabolic acidosis AKI.
• Hyperthermia also puts the patient at risk of
coagulopathies, liver dysfunction,
neuropathies, and seizures.

23. CONTROL OF BODY
TEMPERATURE
• Body temperature is monitored by two probes.
• One temperature probe is placed in the
esophagus/nasopharynx for core temperature
monitoring and the temperature of the abdominal
cavity is measured by thermistors present in the
inlet and outlet drains of the HIPEC machine.
• Thermoregulation plays a significant role in
maintaining the metabolic homeostasis,
coagulation, anti‐inflammatory cascade and
neurological status intact .

24. CONTROL OF BODY
TEMPERATURE
• Warming during CRS to prevent hypothermia
and to prevent coagulation and metabolic
harmful effects .
AND
• During the HIPEC phase, cooling blankets and
cold head-wraps or cooling blocks can be used
to help to regulate the temperature.

25. CONTROL OF BODY
TEMPERATURE
• Cold intravenous fluids and placement of
ice packs in the axillae of the patient may
be required to normalize the temperature .
• If despite all these measures, core body
temperature rises to ≥39°C then the
perfusionist should be advised to reduce the
instillate temperature .

26. Postoperative Complications
Hypovolemia/Hypoproteinemia as the patient loses
4 – 5 liters of PROTEIN – ENRICHED fluid per day.
Bowel
perforation
Anastomotic
and bile leakage
Fistula formation
Postoperative
bleeding or
infections
Venous‐thromboembolic
complications
Postoperative ileus
Complications related to
chemotherapy as leukopenia

27. Postoperative/Critical Care
Management
REFERENCE
• Intensive Care Management of Patient After
Cytoreductive Surgery and HIPEC –
A Concise Review.
Indian J Surg Oncol (June 2016) 7(2):244–248
DOI 10.1007/s13193-016-0511-7.

28. Postoperative/Critical Care
Management
• Postoperative fluid loss during the first 72 hours following surgery
is still very high with values up to 4 liters per day, whereas most of the
fluid loss occurs via abdominal drains (40%) due to the severely
wounded surface .
• Protein loss is remarkable with decreased albumin levels starting to
decline during surgery with the frequent need for exogenous
administration . Supplement Albumin if it falls below 3.0 g/dl
to maintain adequate intra vascular volume.
• Close monitoring of fluid loss and turnover is of critical
importance for the patient’s convalescence.
REFERENCES :
1.Arakelian E, Gunningberg L, Larsson J, et al. Factors influencing early postoperative recovery after
cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2011; 37:897–903.
2. Cooksley TJ, Haji‐Michael P. Postoperative critical care management of patients undergoing cytoreductive
surgery and Heated Intraperiton al Chemotherapy (HIPEC). World J Surg Oncol 2011; 9:169

29. Postoperative/Critical Care
Management
• Vasodilation may occur after HIPEC.
• Vasopressors for patients who are not fluid
responsive to avoid fluid overload.
• Early enteral feeding is recommended,
as nutrition is crucial to promote wound
healing and improve intestinal health.

30. Postoperative/Critical Care
Management
• Maintain an adequate effective circulating volume by
supplying sufficient intravenous fluids such as crystalloid &
colloid solutions or blood and blood products like fresh frozen
plasma.
• ANALGEIA .There is increasing evidence that thoracic
epidural anesthesia (TEA) with local anesthetics and
opioids is superior in the control of dynamic pain, playing a
key role in early extubation and mobilization and reducing
postoperative pulmonary complications.
• TEA Hypotension & Epidural hematoma ?
• Multimodal analgesia is a good alternative.

31. Postoperative/Critical Care
Management
• Postoperative respiratory support is not always necessary.
It was reported that all the patients were extubated
in the OR .
• The coagulation profile takes at least 5 days
to get back to baseline, eventual transfusions are needed .
• Patients with gross ascites often lose in excess of two litters
of ascitic fluid rich in protein (0.5–4 g/dL) which is
primarily albumin.
• Renal Status, Electrolyte Balance, Glycemic Control :
Impairment to these functions is reported to be short lasting.
Standard care is needed.
• Stress Ulcer Prophylaxis.
• Infection Control .

32. Postoperative Care
• Postoperative ileus is a common problem after
CRS and HIPEC.
• Oral intake, regaining bowel functions and mobilization
usually occur between 7 and 11 days postoperatively.
• Patients may experience nausea for up to 13 days
postoperatively.
• Early enteral feeding is both safe and beneficial for
these patients.
• Epidural anesthesia has been recommended by some
as a strategy to reduce postoperative ileus .
Arakelian E, Gunningberg L, Larsson J, Norlén K, Mahteme H.
Factors influencing early postoperative recovery after cytoreductive
surgery and hyperthermic intraperitoneal chemotherapy.
Eur J Surg Oncol 2011;37:897–903

33. Postoperative Care
• Anti-emetic prophylaxis using 5-HT3
antagonists should continue for a few
days at a regular intervals.
• Maintaining Hemoglobin concentration
between 8-10 g/dL according to CV risk.
• Avoid nephrotoxic medications and diuresis
should not fall below 1 mL/kg/hour.
• Hemodynamic monitoring until the third
postoperative day or discharge from ICU.

34. Postoperative Care
• Drain Management Enhancing early
mobilization is an essential element of postoperative
enhanced recovery protocols.
• Tubes and drains carry the risks of infection and can
hinder mobility and cause pain.
• Drains should be removed as early as possible.
• It is recommended to leave only one abdominal
silicone drain for the pelvis, additional drains can
be used especially after splenectomy or (partial)
gastrectomy.

35. Postoperative Care
• Management of Hemodynamics:
REMEMBER that Fluid loss during initial
72 hours after surgery may be as high as
4 liters per day due to oozing of protein-rich
fluid from the raw surface area due to
peritonectomy .
• Most of the patients require vasopressor
support in the early postoperative period to
counteract the vasodilatation due to HIPEC.

36. VASOPRESSOR SUPPORT
In our case of HIPEC operated on Monday
14th of June 2021 at Ismailia Oncology Teaching
Hospital, we have supported the patient`s
circulation by Noradrenaline (Levophed)
vasopressor , Starting with a dose of
0.05 microgram/kg/minute (that is 210 mic/hour)
and raised gradually to 400 mic/hour to
support the circulation and maintain B.P.

38. One mL contains 80 microgram Noradrenaline (Levophed)
Starting dose for a 70 kg patient is :
0.025 mic. x 70 kg x 60 min = 105 microgram/hour = 105/80 =
1.3 mL/hour . To be increased gradually according to patient`s response.
NORADRENALINE INFUSION (Levophed)
4 mg ampoule = 4 mL 0f 1:1000
Add 4 mL of 1:1000 Noradrenaline to 46 mL
Glucose to make 50 mL.
Starting dose : 0.025 – 0.05 microgram/kg/min.
The rate in infusion/syringe pump in mL/hour.

39. CONCLUSION
Perioperative care of patients undergoing cytoreductive surgery
and HIPEC procedure is complex and involves management of
excessive fluid and protein losses, thermoregulation,
coagulation disturbance and postoperative care.

40. • Gupta, et al.: Anesthesia for HIPEC
Journal of Anaesthesiology Clinical Pharmacology | Volume 35 |
Issue 1 | January-March 2019.
• Anesthesia tutorial of the week.
General anesthesia 379
Dr Rosemarie Kearsley, Dr Sine´ ad Egan, Professor Conan McCaul
Anesthesia for cytoreductive surgery with hyperthermic
intraperitoneal chemotherapy (HIPEC) (15 May 2019)

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