Cytoreduction with hyperthermic intraperitoneal chemotherapy: An anaesthetic challenge
A 52-year-old postmenopausal lady weighing 74 kg, diagnosed to have pseudomyxoma peritonei was planned for cytoreductive surgery (CRS) with HIPEC presented to the pre-anaesthesia clinic. She had gross abdominal distension [] and bilateral pitting pedal oedema. Vital signs were within the normal range. Her haemoglobin (Hb) was 7.6 g% and blood group A negative. Echocardiography was normal. Pre-operatively, she was prepared with incentive spirometry and packed cell transfusion to bring her Hb to the optimal level. Our hospital has a policy of improving the Hb to at least 9 g% when major surgery with massive blood loss is anticipated. Prior to surgery anti-aspiration prophylaxis was administered and nasogastric tube was inserted. Intraoperative monitoring included non-invasive blood pressure, electrocardiogram, pulse oximetry, invasive arterial pressure, central venous pressure (CVP), capnography and temperature monitoring. Due to the grossly distended abdomen modified rapid sequence induction was conducted using injection propofol and injection scoline. Following intubation ventilation was difficult with airway pressure reaching 40-42 cm of H2O. We could achieve a tidal volume of only 150 ml, at this point the end tidal carbon dioxide (ETCO2) ranged from 50 to 56 mm of Hg and saturation fell to 76% with a fraction of inspired oxygen (FiO2) 100%. However, bilateral air entry was equal. The surgeons were requested to open the abdomen and do decompression. Over a period of time slowly ventilation improved. Anaesthesia was maintained with air, oxygen, sevoflurane, atracurium and morphine.\nAfter partial removal of mucinous material, airway pressure improved to less than 20 cm H2O and we were able to come down on the FiO2-40% and saturation came up to 100%.\nMucinous material weighing 21 kg was removed from the abdomen. Pan hysterectomy and anterior abdominal peritonectomy was done. After 10 h of surgery with blood loss of around 5500 ml as more than 50% of the procedure was still pending, decision was taken by the team to do the rest of the surgical procedure and HIPEC as a staged procedure. Patient received 8 units of packed cells along with blood products, adequate crystalloids and colloids. Intraoperative arterial blood gas (ABG) was normal with Hb 10 g%. Patient was shifted to post-operative intensive care unit (ICU) for elective ventilation on intravenous morphine analgesia. She was extubated the following day.\nThe second stage was planned after 2 weeks and meanwhile patient was given high protein parentral nutrition, deep vein thrombosis prophylaxis and was advised spirometry. On the day of surgery following an uneventful anaesthesia, total peritonectomy with complete omentectomy was done. HIPEC was initiated by a CLOSED technique [], five drainage tubes (two inlet and three outlet tubes) were inserted into the abdomen and skin closed. Perfusate was peritoneal dialysis fluid along with chemotherapy agent mitomycin C at a temperature of 42°C. The solution was circulated for 70 min in the abdominal cavity by tilting the operation table in different directions and by shaking the patient to facilitate the circulation of the solution. During the HIPEC period, a raise in body temperature above 42 should be alerted to the perfusionist so temperature should be recorded at 15 min interval, similarly, urine output should also be measured at 15 min interval as most of the chemotherapeutic agents are nephrotoxic, blood sugar and lactate were monitored every 15 min.[] ABG was checked at 30 min interval. Throughout, the procedure patient was haemodynamically stable with adequate urine output. The surgery lasted for 7 h with blood loss of 3500 ml. Six units of blood and other blood products along with adequate crystalloids and colloids were replaced. At the end of the procedure, cooling measures were adopted by switching our warming blanket (Geratherm Operation System) to the cooling mode at 34°C, we used cooled saline to replace the lost volume and icepacks wrapped in sterile sheets were placed in the groin and axilla by the surgeons. Our observation was that temperature gradually came down to normal within 30 min. Patient was shifted to ICU for elective ventilation, the next day she was extubated without complications.