Anesthesiology in advanced radical surgery. Bruno Carrara Ospedali Riuniti di Bergamo

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1 Anesthesiology in advanced radical surgery Bruno Carrara Ospedali Riuniti di Bergamo

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4 Anesthetic considerations

5 Anesthesiology in advanced radical surgery Anesthesiologists's task is to minimize the contribution to perioperative morbidity and mortality

6 Anesthesiology in advanced radical surgery Morbidity rates after CRS and PIC varied from 30% to 74%. Mortality ranged from 0% to 19% in the literature and from 0% to 8% in the main series

7 Morbidity and Mortality

8 Morbidity and Mortality

9 Anesthesiology in advanced radical surgery Anesthesiologists and surgeons alike should have an understanding of the profound hemodynamic and metabolic perturbations associated with the therapy.

10 Hemodynamic and Metabolic implications of CHPP

11 Hemodynamic management Hemodynamic monitoring Fluid therapy Vasoactive drugs Diuretics

12 Hemodynamic monitoring Swan-Ganz PiCCO Flotrac TEE

13 Hemodynamic monitoring Swan-Ganz: pulmonary artery catheter - Cardiac output - SVO 2 - CVP/ PAWP - SVR/PVR

14 Hemodynamic monitoring PiCCO PCCI: pulse contour cardiac index GEF: global ejection fraction GEDV: global end diastolic volume / ELWI: extravascular water index SVR: systemic vascular resistences / SVV: stroke volume variation

15 Hemodynamic monitoring TEE: trans-esophageal echocardiography - Pre-load - Conctractility - Segmental motion - Embolism - Large vessels

16 Intra-operative fluid therapy

17 Intra-operative fluid therapy

18 Intra-operative fluid therapy

19 Vasoactive drugs Vasoactive drugs are administered to treat decreases in arterial blood pressure (aiming to keep the mean arterial pressure above 60 mmhg) or to facilitate diuresis during CHPP. Patients received: - 37%: dopamine - 19%: phenylephrine and/or ephedrine.

20 Metabolic implications of CHPP - Persistent metabolic acidosis significant decreases in ph, bicarbonate - Anemia - Coagulopathy significant decreases hematocrit and platelet counts significant increases in aptt, PT - Impairment in gas exchange significant increases oxygen A-a gradient

21 Metabolic implications of CHPP

22 Metabolic implications of CHPP

23 Metabolic management Metabolic monitoring Coagulation monitoring Fluid therapy Urine output

24 Metabolic monitoring Haemo gas analysis: Ph PaO 2 PaCO 2 Hb sat HCO 3 Hb/Ht Ca ++ - Na/K Glic Lactate

25 Fluid management

26 Coagulation monitoring

27 Urine output

28 Temperature

29 Hemodynamic and Metabolic implications of CHPP When addressed timely, these changes are short lived, variables return to baseline

30 Thoracic epidural analgesia Supplementary thoracic epidural analgesia can be recommended to guarantee: - adequate pain therapy and - to reduce the rate and duration of postoperative ventilation as well as postoperative intravenous opioid administration.

31 Thoracic epidural analgesia

32 Thoracic epidural analgesia Risks: - Hemodynamic intolerance and acute episodes of hypotension through blockade of sympathetic nerve system - Thrombopenia and perturbations in blood coagulation are often observed during HIPEC and are a risk factor of spinal haematoma after epidural analgesia.

33 Thoracic epidural analgesia Haematoma formation in the spinal canal due to epidural anesthesia is a serious but very rare complication. Were reported about 51 confirmed spinal haematomas associated with epidural anesthesia in 29 years of medline and case report research

34 Thoracic epidural analgesia Most of them were related to the insertion of a catheter and a difficult or traumatic procedure. Following the general guidelines for neuraxial anesthesia, the above-mentioned benefits of perioperative epidural anesthesia outweigh in our opinion its very rare side effect.

35 Conclusion We showed that cytoreductive surgery and CHPP with cisplatin is associated with significant hemodynamic and metabolic perturbations that, if anticipated and diagnosed timely, are transient, easily treated, and unlikely to contribute to major morbidity or mortality.