Anton Bilchik, MD
Dr. Bilchik requests that the anesthesiologist assigned to his room please text him night before
so he can communicate any concerns directly to anesthesiologist
Anesthetic Considerations for Cytoreductive Surgery and HIPEC
Cytoreductive surgery (CRS) with hyperthermic intra-peritoneal chemotherapy (HIPEC) is an extensive, invasive procedure that presents unique physiological challenges.
During the HIPEC portion of the surgery, patients develop a hyperdynamic state.
A balanced approach to fluid management, which incorporates both crystalloids and colloids, is encouraged.
Hemodynamic monitoring with estimation of cardiac output is useful for optimizing organ perfusion while preventing fluid overload.
To avoid renal injury by chemotherapeutic agents, urine output should be maintained at a high rate during that phase of the procedure.
Thoracic epidural anesthesia improves analgesia and facilitates early mobilization of patients.
Unlike the third space, the volume-expanding effects of crystalloid solutions are well characterized. After 1 hour, only 200 mL of a 1-L crystalloid bolus remains in the intravascular space, with the remainder in the interstitium. This extravascular fluid has no volume-expanding effect, and may impair pulmonary function, and interfere with the healing of gut anastomoses. In extreme cases, perioperative weight gain secondary to crystalloids may be linked to increased mortality. Finally, it should be noted that the administration of large volumes of any type of intravenous fluids may cause dilution of platelets and coagulation factors, resulting in clinically significant coagulopathy.
Currently at our institution, continuous noninvasive cardiac output monitoring, as well as urine output, is used to guide fluid administration throughout the procedure.
The non-invasive nature of this monitoring confers several advantages. Baseline stroke volume index may be obtained before the induction of anesthesia, and volume responsiveness can be established by performing a passive leg raise test (PLR). PLR causes an endogenous fluid challenge of approximately 200 mL, by moving blood normally sequestered in the calf veins into the central circulation. Patients with a 10% increase in cardiac index owing to position change are considered volume responsive. No response to PLR signifies euvolemia, or possibly depressed left ventricular function. During surgery, decreases in stroke volume index may occur because of hypovolemia, venodilation, blood loss, or decreases in venous return from mechanical causes. Fluid responsiveness is also suggested by increases in SVV. Initial therapy in this setting is generally a 500-mL colloid bolus with either 5% albumin or third generation hydroxyethyl starch (Voluven, HES 130/0.4, Hospira, Inc, Lake Forest, IL, USA). Transfusion with packed red blood cells is rarely necessary. In our experience, typical estimated blood loss averages 300 to 500 mL.
Both human derived and synthetic colloids provide 1:1 volume-expanding effects for several hours hours. Voluven is favored over first-generation hydroxyethyl starches (Hespan, Hextend) for a variety of reasons. Voluven is a small molecule that is more freely filtered by the kidney, resulting in substantially less plasma and tissue accumulation, and risk of nephrotoxicity. In addition, its effect on Factor VIII and von Willebrand appear to be clinically insignificant. Patients with substantial ascites or who require extensive surgical debulking are at risk for clinically significant protein losses. Because of this, such patients may benefit from volume expansion with albumin as opposed to hydroxyethyl starch.
Because some chemotherapeutic agents are nephrotoxic, maintenance of steady urine output is encouraged. Unfortunately, it is not known to what degree urine output must be maintained, and the link between intraoperative urine output and postoperative creatinine elevation is unclear. At our institution, the goal is to maintain 100 mL every 15 minutes of urine output for the duration of the hyperthermic perfusion. In some patients, urine output of 50 to 75 mL every 15 minutes may be acceptable. In addition to ensuring euvolemia with administration of both colloid and crystalloids, low-dose dopamine infusion is initiated 15 to 30 minutes before infusion of Mitomycin C and is infused only for the 90 minutes of heated perfusion. Dopamine is a nonselective DA1 and DA2 agonist with multiple dose-related effects. Although dopamine may not afford additional renal protection per se, renal perfusion may be enhanced secondary to increased cardiac output, perfusion pressure, and renal blood flow. Stimulation of DA1 receptors causes renal vasodilation as well as inhibition of active sodium transport in the proximal tubule, leading to natriuresis and dieresis, which is clinically reassuring. Furosemide should be administered only when urine output is inadequate despite confirmation of adequate intravascular volume and renal perfusion.
The infusion of heated chemotherapy solution causes a gradual rise in core temperature.
The temperature and urine output must be documented every 15 minutes and communicated to the surgeon and perfusionist. At some institutions, core temperature is controlled using a combination of cooling and warming regimens at the various stages of the surgery. The surgeon or perfusionist should decrease the temperature of the perfusate when the core temperature approaches 39C. Of note, there may be disparity of temperature measurements depending on the temperature probe site. In our experience, rectal temperature may exceed nasopharyngeal temperature, possibly owing to local intraperitoneal heat transfer. Additional heat transfer to the patient should be avoided during the chemotherapy phase. At a minimum, fluid warmers must be turned off and forced air warmers should be set to ambient temperature.
A strategy used in our institution is to allow patient temperature to drift to 35.5C before the start of HIPEC.
A variety of acid-base and electrolyte disturbances have been reported in the setting of HIPEC surgery and may vary with the type of chemotherapeutic agents used. Oxaliplatin may predispose patients to lactic acidosis, hyperglycemia, and hyponatremia. Cisplatin may aggravate low magnesium levels, culminating in cardiac dysrhythmias. Approximately 15 minutes before the start of heated chemotherapeutic infusion, a set of laboratory studies is obtained, including chemistries, arterial blood gas, and hemoglobin. Many patients will require electrolyte replacements, most commonly calcium, magnesium, and potassium. Therefore, rechecking electrolytes after the chemotherapy phase of the procedure is prudent. In our experience, the development of acidosis is rare, particularly if adequate cardiac output is maintained.
A checklist provides a useful strategy for ensuring that key tasks are accomplished 15 minutes before starting HIPEC:
1. Fluid warmers off
2. Forced air warmer temp set to ambient
3. Laboratory studies obtained
4. Low-dose dopamine infusion initiated
5. Crystalloid infusion rate sufficient to support urine output 100 mL / 15 minutes
6. Temperature communicated to surgical team every 15 minutes
7. Repeat antibiotics as indicated
8. Maintain nominal stroke volume index with 250 to 500-mL colloid boluses as needed
MALS (Median Arcuate Ligament Syndrome) Patients
1. Please contact the Pain Service (424-305-6095) the night before surgery and request a pre-operative consult. Pain Service will see the patient in the morning before surgery and assist with post-operative pain orders.
2. Pre-medicate the patient with Tylenol and Gabapentin. See ERAS protocol for dosing. Also can use Lyrica (50-150 mg) if patient is intolerant to Gabapentin.
3. INTRATHECAL DURAMORPH for all of his MALS patients. It's up to each individual anesthesiologist if they also want to use spinal Bupivacaine during the case (but remember that he also wants general anesthesia on top of the spinal so if I do use local anesthetic in the spinal I reduce the dose to avoid hypotension).
Doses for IT Duramorph:
- Age < 50: up to 0.3 mg
- Age 50-59: 0.2 mg
- Age 60-69: 0.15 mg
- Age 70-79: 0.1 mg
- Age > 80: Not recommended
4. General anesthesia with ETT. Keep the patient well paralyzed throughout the case. OG tube to decompress the stomach. Standard anti-emetics. Limit additional opioids. Toradol towards the end of the case (unless contraindicated).
5. Fluid management: ERAS protocol recommends goal-directed or restricted fluid management to prevent bowel edema. Standard suggestions are less than 500 mL/hour or 2 liters total for a case. Not as imperative for these cases as they are not doing any bowel anastamosis.
6. Bilateral TAP blocks at the end of the case. He does not use Exparel for these cases so you can use Bupivacaine or Ropivacaine. Max dose for Bupivacaine and Ropivacaine are 2-3 mg/kg. 2.5 mg/kg of either of those local anesthetics and then dilute that volume out into a total of 40cc using normal saline. Then use 20cc on each side of the TAP Block.
7. Other considerations: If the patient is on opioids at home or you feel like they are going to have pain control issues post-operatively, consider using a Ketamine gtt during surgery. A recommended dose is 20 mg IV with induction and then run a gtt at 5-10 mg/hr.
8. As a courtesy, you might want to give some kind of sign out / report to the Pain Service as they will be following the patient. Also make sure the Pain Service wrote for post-op pain management orders. If they haven't had time to, please communicate to the surgical team that they are responsible for putting those orders in. Basically, Dr. Bilchik just wants some consistency with pain management for these patients so that patient's are not admitted to the floor without any pain medication orders.
ERAS Protocol for Abdominal Cases
Patient is already given instructions they can drink Apple Juice and Gatorade up to 4 hours before surgery
Pre-med with acetaminophen +/-gabapentinoid +/-NSAID (note: gabapentin causes more post-op drowsiness than Lyrica/pregabalin)
Do a spinal with DUROMORPH (unless contraindicated, see dosing suggestion) – put in order set “Anesthesia Neuraxial Single dose” when you do this procedure. This will include orders for continuous pulse oximetry as well as medications for respiratory depression and pruritus
Intrathecal Morphine Dose by Age
< 50: 0.3 mg
50-59: 0.2 mg
60-69: 0.15 mg
70-79: 0.10 mg
> 80: not routinely recommended, use judgement
4. Give less IV fluids if patient can tolerate it
5. Consider TAP block after the procedure – if you don’t do TAP blocks, call AIC and they will assign someone to
perform TAP block, use Exparel in block
Narcotic-Sparing Pain regimen
Surgeons write their own preoperative medications
Caution in patients with liver disease
do not exceed 4g in 24 hours
start at least 6 hours after last dose
Caution in patients with prior GI bleed or renal dysfunction
All patients: celecoxib 400mg x1/ibuprofen 600mg x 1/naproxen 500mg x1
Patients >65 yrs, <50kg, or CrCl 30-50 ml/min: celecoxib 200mg x1/ibuprofen 400mg x1/naproxen 250mg x1
Creatinine >1.5, CrCl <30ml/min – no NSAID recommended
Gabapentinoids (Gabapentin & Lyrica)
Consider lower dose or patients with OSA, age >65, or neuroaxial opioids
All patients: Gabapentin 300-600mg x1, Lyrica 75-150mg x 1
Patients >65, CrCl 30-50 mL/min, h/o OSA or STOP BANG 5 or greater: Gaba 300mg, Lyrica 75mg
Patients Cr>1.5, CrCl <30mL/min: no gabapentinoid agent recommended