Anesthesiology in advanced radical surgery Bruno Carrara Ospedali Riuniti di Bergamo
Anesthetic considerations
Anesthesiology in advanced radical surgery Anesthesiologists's task is to minimize the contribution to perioperative morbidity and mortality
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
Morbidity and Mortality
Morbidity and Mortality
Anesthesiology in advanced radical surgery Anesthesiologists and surgeons alike should have an understanding of the profound hemodynamic and metabolic perturbations associated with the therapy.
Hemodynamic and Metabolic implications of CHPP
Hemodynamic management Hemodynamic monitoring Fluid therapy Vasoactive drugs Diuretics
Hemodynamic monitoring Swan-Ganz PiCCO Flotrac TEE
Hemodynamic monitoring Swan-Ganz: pulmonary artery catheter - Cardiac output - SVO 2 - CVP/ PAWP - SVR/PVR
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
Hemodynamic monitoring TEE: trans-esophageal echocardiography - Pre-load - Conctractility - Segmental motion - Embolism - Large vessels
Intra-operative fluid therapy
Intra-operative fluid therapy
Intra-operative fluid therapy
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.
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
Metabolic implications of CHPP
Metabolic implications of CHPP
Metabolic management Metabolic monitoring Coagulation monitoring Fluid therapy Urine output
Metabolic monitoring Haemo gas analysis: Ph PaO 2 PaCO 2 Hb sat HCO 3 Hb/Ht Ca ++ - Na/K Glic Lactate
Fluid management
Coagulation monitoring
Urine output
Temperature
Hemodynamic and Metabolic implications of CHPP When addressed timely, these changes are short lived, variables return to baseline
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.
Thoracic epidural analgesia
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.
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
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.
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.