Review Article

Anesthetic implications in hyperthermic intraperitoneal

chemotherapy

Nishkarsh Gupta, Vinod Kumar, Rakesh Garg, Sachidanand Jee Bharti, Seema Mishra,
Sushma Bhatnagar
Department of Onco‑Anesthesiology and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India

Abstract
Patients with peritoneal carcinomatosis were considered incurable with dismal survival rates till hyperthermic intraperitoneal
chemotherapy after optimal cytoreductive surgery evolved. Perioperative management for these procedures is complex and
involves an optimal cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy. In this article we highlight
the perioperative concerns in these patients including anesthetic challenges, such as optimal fluid management, maintaining
blood pressure, control of body temperature, coagulation and electrolyte derangement and renal toxicity of chemotherapeutic
drugs. We have also discussed the postoperative problems and their management.

Keywords: Anesthesia, fluid management, hyperthermic intraperitoneal chemotherapy, postoperative care

Introduction surgical colleagues for the care of these patients improves

patient outcomes.
Primary peritoneal neoplasm and metastasis to peritoneum
from gynecologic or gastrointestinal cancer have a very poor History
prognosis. They were considered an incurable palliative
condition for long until, Dr Paul Sugarbaker showed that Cytoreductive surgery for ovarian cancer was first described
surgical removal of visible tumour for peritoneal mesothelioma by Joe Vincent Meigs in New York to reduce macroscopic
combined with loco‑regional heated chemotherapeutic drugs disease.[2,3] Subsequently effect of hyperthermic intraperitoneal
improved quality of life and survival of patients.[1] Nowadays, chemotherapy on killing cancer cells was established. This
this hyperthermic intraperitoneal chemotherapy (HIPEC) led to development of modern HIPEC procedure. A short
is a well‑established treatment for pseudomyxoma peritonei, history is described in the Table 1.
and colorectal, ovarian and gastric cancers with isolated
peritoneal metastases. Perioperative management is complex Rationale
and is associated with massive fluid shift, blood loss,
temperature imbalance and hemodynamic alterations. The Intraperitoneal delivery ensures high concentrations of the
anesthesiologist plays an important role during HIPEC cytotoxic drug in the local tumor‑bearing peritoneum uniformly
and cytoreductive procedure. A team approach with the and keeps the systemic drug levels low. A “Three Compartment
Model” is suggested wherein a high concentration gradient of
Address for correspondence: Dr. Nishkarsh Gupta, chemotherapeutic drug is maintained between the peritoneal
Department of Onco‑Anesthesiology and Palliative Medicine,
DR BRAIRCH, AIIMS, New Delhi, India.
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DOI: How to cite this article: Gupta N, Kumar V, Garg R, Bharti SJ,
10.4103/joacp.JOACP_93_18 Mishra S, Bhatnagar S. Anaesthetic implications in hyperthermic intraperitoneal
chemotherapy. J Anaesthesiol Clin Pharmacol 2019;35:3-11.

© 2019 Journal of Anaesthesiology Clinical Pharmacology | Published by Wolters Kluwer - Medknow 3

 Gupta, et al.: Anesthesia for HIPEC

Table 1: History of development of modern hyperthermic The important parameters that need to be assessed during the
intraperitoneal chemotherapy procedure screening of the patients for the surgery include:
Year Development 1. Preoperative cancer index (PCI) describes the volume
1979-1980 TIFS developed to deliver heated chemotherapy and extent of disease radiologically. It integrates peritoneal
into the peritoneum and tested in humans for
administration of HIPEC for locally advanced
implant size and distribution of peritoneal nodules.
abdominal malignancy[4] The abdomen and pelvis are divided into 9 regions
Mid to late Dr. Sugarbaker reported survival benefits in and intestines are divided into 4 regions. Each lesion is
1980s patients with peritoneal dissemination[1] measured and given a score on basis of size (LS‑0 denotes
1995 Dr. Sugarbaker standardized the procedure and
described stepwise approach to cytoreduction[5]
absence of cancer; LS‑1 tumor size <0.5 cm in
2016 LE‑HIPEC technique described where the HIPEC diameter; LS‑2 tumor deposit 0.5‑5 cm and LS‑3 tumor
given after the closure of the abdominal wound and deposit >5 cm). The PCI score is calculated by adding
spread with the help of laparoscopic approach[6] scores for each region to get a score between 1‑39.[12,13] It
HIPEC=Hyperthermic intraperitoneal chemotherapy, TIFS=Thermal transfusion
infiltration system, LE=Laparoscopy‑enhanced
is an important, commonly used and validated prognostic
index. A PCI >17.4 doesn’t decrease the chances of any
cavity and the plasma by this ‘peritoneal‑plasma barrier’ benefit with HIPEC and if PCI is >20 HIPEC should
(third compartment).[7] Portal vein carries cytotoxic drug not be done.
from peritoneal surface to liver as first pass metabolism and 2. Histopathology of the tumor for invasiveness of
ensures exposure of hepatic micrometastasis to cytotoxic malignancy is an important parameter to be considered
chemotherapy.[8] before HIPEC in patients with low‑grade disseminated
peritoneal adenomucinosis and high‑grade peritoneal
Tissue penetration mucinous carcinomatosis.[14] HIPEC may be beneficial
The intraperitoneal chemotherapy penetrates tissues upto a in patients with PCI >20 also and decision should be
depth of 5mm only. So before intraperitoneal instillation of individualized based on other patient factors. Patients
drug, adequate cytoreductive surgery should be performed with histopathologically proven extra‑abdominal
to remove visible tumour mass to ensure penetration of the disease, extraperitoneal disease like >3 liver metastases,
chemotherapy into the remaining tumor cells.[9] retroperitoneal lymph nodes or unknown primary tumour
are contraindications for HIPEC surgery.[15]
Hyperthermia 3. Preoperative CT scan to ascertain the extent of extra
Hyperthermia in the range of 41 to 43ºC causes selective abdominal spread in the thorax, and pelvis.
destruction of malignant cells by reversible nonselective 4. Completeness of the cytoreduction (CC) score is an
inhibition of RNA synthesis and mitosis arrest. It increases important prognostic indicator on basis of the visible
the tissue penetration for the drug, leads to vascular tumor left after cytoreduction.(CC‑0 no visible tumor;
stasis in the microcirculation of malignant tumours and CC‑1 persisting tumor nodule <2.5 mm; CC‑2
results in anaerobic glycolysis and acidosis. This acidic tumor nodule between 2.5mm‑2.5cm and CC‑3 tumor
microenvironment in malignant cells induces lysosomal nodule >2.5 cm).[12] A score of CC‑0 or CC‑1 are ideal
enzymes and causes accelerated death of fragile malignant candidates for HIPEC after cytoreduction.
cells.[10]
Technique
Enhanced cytotoxicity of heated There are two methods for intraperitoneal administration of
chemotherapeutic drugs hyperthermic chemotherapy:
Heat and cytotoxic drugs act synergistically to increase the a. The Open abdomen technique is performed by the
drug uptake in malignant cells by improving membrane “Coliseum technique”, as described by Sugarbaker.[16]
permeability and transport. Heat causes changes in The infusate is maintained at a temperature of 43‑45ºC
pharmacokinetics and pharmacodynamics of chemotherapy to ensure a temperature of 41‑43ºC of the intraperitoneal
drugs and increases drug penetration and its action in fluid [Figures 1 and 2]. The drug in the perfusate is
tissues.[11] recirculated within the peritoneal cavity to maintain
a minimum intraperitoneal temperature of 41.5ºC.
Indications of hyperthermic intraperitoneal This ensures even distribution of temperature or
chemotherapy chemotherapeutic drug throughout the abdominal cavity.
Appropriate patient selection is the most challenging step in An open approach allows direct access of the cavity during
the success of the HIPEC procedure. The benefits may be administration of chemotherapeutic drugs and allows for
minimal in patients with advanced intra‑abdominal disease. manipulation of fluid and bowel for optimal distribution of

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 Gupta, et al.: Anesthesia for HIPEC

drug within the abdomen. But it is difficult to achieve and HIPEC surgery are hemodynamic fluctuations, hypothermia
maintain hyperthermic state due to the heat dissipation by and induced hyperthermia, the potential for chemotherapeutic
the exposed abdomen. Moreover, heated chemotherapy drug induced nephrotoxicity. Anesthesiologists need to
may lead to aerosolisation and cause inhalational exposure manage intravenous fluid therapy, blood transfusion and
of operating room personnel. electrolyte balance to maintain optimal end‑organ perfusion,
Peritoneal cavity expander (PCE) is a modified open and prevent renal injury.
technique. It consists of an acrylic cylinder with in‑flow
and out‑flow tubes that are secured over the wound. The Preoperative Concerns
small bowel floats freely and manually manipulated in
the PCE filled with heated perfusate. This ensures more 1. Operative risk assessment for comorbidities like diabetes,
uniform distribution of the drug as compared to a closed hypertension and heart disease and their implications and
technique. It may lead to oozing around the wound and additional risk to previous radiotherapy and chemotherapy.
tumor recurrence inside parietal wound Traditionally ASA classification is done to assess risk of
b. In closed technique, after cytoreduction the temperature anesthesia.[18] In addition Eastern Cooperative Oncology
probes and catheters are placed to instill chemotherapy Group (ECOG) performance status of patients should
and abdomen wall is sutured prior to infusion of be assessed.[19] It describes a patient’s functional status
chemotherapy. Due to closed abdomen, intraabdominal in terms of their ability to care for themself, daily activity,
pressure rises which helps in deeper tissue penetration and physical ability. The surgery is extensive and may
of drug, this reduces the heat loss to minimal and require prolonged hospital stay. The patients and their
ensures that hyperthermia is easy to achieve and caregivers should be informed regarding therapy, expected
maintain. The advantage of closed technique is that outcome, cost involved, risk involved, quality of life and
there is minimal exposure of the operating theatre need for systemic chemotherapy
personnel to aerosolized chemotherapy. However, the 2. Prehabilitation is an important part of preparation for a
disadvantage of closed technique is that it may lead to good surgical outcome. It should include:
uneven distribution of the hyperthermic chemotherapy, a. Patient`s preoperative nutritional status and albumin
the drug may pool and accumulate in dependent parts levels strongly predicts length of hospital stay and
of the abdomen and lead to postoperative ileus, bowel overall survival in these patients.[20,21] Malnutrition
perforation, and fistula. may be present in >50% patients with ovarian cancer
and advanced colorectal cancer with peritoneal
Anesthetic Implications metastasis. Preoperative malnutrition may lead to
prolonged hospital stay, increased complications
The anesthesiologist has a crucial role during HIPEC and and cost of care. Some of the clinical indicators
cytoreductive procedure. A team approach for care of these of malnutrition include weight loss >5% in past
patients improves patient outcomes.[17] Unique aspects of three months, reduced intake and a Body Mass
Index (BMI) <18.5 kg/m2.[20,21] There is limited

Figure 1: Coliseum technique of HIPEC: After cytoreduction, Tenckhoff catheter

and closed suction drains are inserted in abdominal wall for administration of
HIPEC Figure 2: Hyperthermic intraperitoneal chemotherapy machine

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 Gupta, et al.: Anesthesia for HIPEC

literature on preoperative nutrition building in and malignancy predispose these patients to risk for
HIPEC patients but well accepted guidelines for thrombosis. Various studies have reported deranged
surgical patients can be used. The nutritional support prothrombin time (PT) with international ratio (INR),
preferably enteral should be instituted to improve decreased AT III and fibrinogen values, a prolonged
anemia and albumin actived partial thromboplastine time (aPTT) and
b. Patients coming for HIPEC surgery often have a thrombocytopenia.[24] Additionally, patients may
ascites and pleural effusion. This may lead to basal have platelet dysfunction due to extreme variation in
atelactasis and predispose the patients to increased the temperature. Advanced point of care coagulation
risk of postoperative respiratory complications. monitoring such as thromboelastography (TEG) may
Intensive spirometry should be prescribed in the help to detect complex coagulation disorders such as
preoperative period to reduce the incidence of hyperfibrinolysis, thrombocytopathia, or factor XIII
pulmonary complications[22] deficiency[25]
c. Patients undergoing HIPEC surgeries are at increased c. These patients have a large laparotomy
risk of venous thrombo‑embolism (VTE) and a incision and should be provided with good
decision to start VTE prophylaxis (preoperatively perioperative analgesia.[24] Primary opioid based
and 4‑6 weeks postoperatively) using heparin (low analgesia (Morphine) should be used with caution
molecular weight/unfractionated) and/or mechanical as it may be associated with increased respiratory
pneumatic compression stockings should be taken complications and need for ventilator support.
3. Pulmonary function assessment and management: These Epidural provides good analgesia but is associated
patients may have ascites and pleural effusion which with an increased risk of hemodynamic disturbance
leads to diaphragmatic splinting and basal atelectasis due to extensive surgery and these patients are prone
and predispose them to hypoxia in preoperative period. to develop spinal hematoma due to coagulation
A detailed medical history and investigations (CXR/ abnormalities and thrombocytopenia. So, the
CT, arterial blood gas (ABG) analysis, pulmonary coagulation abnormalities should be assessed and
function tests, cardiopulmonary exercise testing (CPET) documented to be normal before the insertion and
if feasible should be done to determine pulmonary removal of epidural catheter and ensure that the
function.[23] procedure is atraumatic and done by experienced
4. Cardiovascular assessment: Large amount of fluid shift anesthesiologists to avoid complications.[26] Also,
occurs during cytoreductive phase due to large raw this should be timed according to the effect
surface produced by peritonectomy, ascitic drainage and of the anticoagulant drug being used. Other
significant blood loss during this procedure. In addition alternative techniques for analgesia like paravertebral
hyperthermia during HIPEC leads to peripheral blocks (single and continuous) and sub costal TAP
vasodilatation and reduction in peripheral vascular block provide good alternatives with less side effects.
resistance and mean arterial pressure. This leads to
hyperdynamic circulation with increase in heart rate, 2. Invasive monitoring
central venous pressure (CVP), cardiac index.[21,23] During the heated chemotherapy phase hyperthermia
leads to vasodilatation and hyperdynamic circulation
Intraoperative Concerns with tachycardia and increased cardiac output. This
normalizes after completion of the heated therapy. In
1. Induction and maintenance of anesthesia addition increased intra‑abdominal pressure in the closed
a. These patients usually have abdominal distension abdomen technique, may further decrease venous return
due to ascites which decreases functional residual and aggravate hemodynamic instability.[27] Functional
capacity. This may predispose the patient to hemodynamic monitoring in the form of CO, SVV and
increased desaturation and aspiration. So, rapid DELTA SV particularly when PCI is recommended
sequence induction should be considered for >15 to guide the goal directed fluid therapy to maintain
induction of anesthesia in these patients[15] normovolemia and prevent acute renal failure. [28]
b. Patients undergoing HIPEC are prone to coagulation Extravascular lung water (EVLW) is the amount of
abnormalities in the perioperative period due to water that is present outside the pulmonary vasculature.
preoperative chemotherapy, nutritional deficiencies It includes interstitial, intracellular, alveolar and lymphatic
and hypoalbuminemia due to ascitic fluid drainage. fluid and does not include pleural effusions. Measurement
The long duration of surgery, female gender, old age of EVWL using volume view of Vigileo (EV1000)

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 Gupta, et al.: Anesthesia for HIPEC

measuring lung water is particularly helpful in predicting Table 2: Common end organ toxicities of various
fluid overload and overall morbidity during and after chemotherapy drugs during Hyperthermic intraperitoneal
HIPEC[29] chemotherapy
a. Decision to put central venous lines (CVP)/pulmonary Chemotherapy Adverse effects
drug
artery (PA) catheter should be individualized as
Cisplatin Nephrotoxicity, peripheral neuropathy,
their usefulness in predicting fluid responsiveness myelotoxicity
is limited. CVP and PA pressures are static Oxyplatin Neurotoxicity (laryngeal/pharyngeal dysthesia),
parameters and maynot reflect volume status or gastrointestinal bleeding
volume responsiveness accurately, but a change in Doxorubicin Cardiotoxicity (arrhythmia, cardiomyopathy),
myelotoxicity
parameters over a period may help us to guide the Mitomycin C Nephrotoxicity, Pulmotoxicity, Myelosupression
fluids.[30] Also these patients will require vasopressors Irinotecan Myelotoxicity
so a CVP line can be used for giving the vasopressors
to maintain the blood pressure
prevented by convective warming devices like forced
b. An arterial line is a must to monitor beat to beat blood
air warming blankets (Bair Hugger ®), warm
pressure to guide inotropes and ABG sampling
intravenous fluids and increased ambient operating
c. Positive pressure ventilation‑induced changes in
room temperature
stroke volume on a rhythmic basis can be useful to
c. During HIPEC phase the patients usually develop
predict fluid responsive subgroups
d. In high risk patients cardiac output monitoring using raised core body temperature (nasopharyngeal) of up
Flotrac/Vigileo may be considered to 40.5°C due to the hyperthermic perfusate. This
e. The addition of dynamic measures of cardiac leads to hypermetabolic phase and hyperdynamic
preload and fluid responsiveness, such as CO, SV, circulation. Due to systemic hyperthermia peripheral
and SVR, may help us to implement goal (or flow) vasodilatation occurs which causes heat loss from
directed fluid therapy. the core to the periphery and environment. Thus
3. Drugs given in HIPEC are hydrophilic, have high the anesthesiologist must maintain normothermia by
molecular weight and a slow peritoneal clearance. setting the warming device to ambient or off mode and
Patient`s height, weight and body surface area should using the underbody mattress to cool the patient. Cold
be documented to calculate doses of anesthesia drug and intravenous fluids and placement of ice packs in the
chemotherapy and the dose modifications in renal, hepatic axillae of the patient may be required to normalize the
and cardiac dysfunction. The specific side effects of the temperature. If despite all these measures, core body
chemotherapy drugs used and drug‑specific potential temperature rises to ≥39°C then the perfusionist
toxicities should be known, preempted and managed by should be advised to reduce the instillate temperature.
the anesthesiologist[31] [Table 2]. 5. Fluid management
a. During cytoreduction of the tumor the intraoperative
4. Perioperative thermoregulation fluid loses may be as high as 8‑12 ml/kg and
a. Extreme temperature fluctuation is very crucial in may be associated with significant blood loss
these patients. So; body temperature is monitored depending upon the extent of resection.[18] During the
by two probes. One temperature probe is placed in HIPEC phase the saline enriched chemotherapeutic
the oesophagus for core temperature monitoring and drug may increase the intra abdominal pressure,
the temperature of the abdominal cavity is measured decrease venous return and decrease the cardiac
by thermistors present in the inlet and outlet drains output.[33] Since this procedure leads to massive
of the HIPEC machine.[18,32] Usually at least 3 to 4 fluid shift, intraoperative crystalloids and colloids are
probes are placed in the abdominal cavity during administered to ensure adequate perfusion pressure
HIPEC 2 in sub diaphragm and 2 on both sides of and urine output without causing fluid overload.[34]
pelvis. It is essential to maintain temp >41 at least Patients with poor cardiac reserve maynot tolerate
in all areas a high volume of intravenous fluid, and may require
b. During debulking phase patients are prone to vasopressors and inotropes to be used judiciously
hypothermia due to extensive surgical resection and b. These patients may have a blood loss from few
exposure, excessive fluid loss and prolonged duration hundred ml to up to 9000 ml due to surgical
of surgery. An intraoperative core hypothermia reasons and coagulation abnormalities. [18] The
should be prevented to prevent coagulation and patients with higher disease load, high PCI
metabolic derrangements.[23] Hypothermia can be and with extensive resections may require blood

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 Gupta, et al.: Anesthesia for HIPEC

transfusions.[18] If available salvage of lost blood increases the risk of renal injury.[42] Intraoperative
with subsequent irradiation (50 Gy) to eliminate measurement of urine output is a reliable, non‑invasive
cancer cells can be considered as an alternative to and a surrogate marker of renal perfusion. One
transfusing large volumes of banked blood as this should aim at a minimum urine output of 0.5ml/kg/hr
blood is more physiological and may be associated during cytoreduction; 2‑4ml/kg/hr during HIPEC
will less transfusion related problems.[35] Various phase and 1‑2ml/kg post‑HIPEC.[42] The diuretic
studies have suggested a lower transfusion trigger should only be given after ensuring euvolemia and
from 6‑8 g/dl to reduce 30 day morbidity and optimal renal perfusion.[43]
mortality.[36] A recent study has suggested that a 6. Intraoperative electrolyte disturbances[44]
liberal transfusion trigger of 9 g/dl reduces major a. The type and volume of carrier fluid for the cytotoxic
postoperative complications in patients having drugs affects their systemic absorption during
major cancer surgery.[37] It may be difficult to HIPEC. The carrier solution is mostly normal
access the accurate blood loss in these patients and saline and traditionally dextrose containing fluid
traditional methods of measurement of hemoglobin is used with oxaliplatin because it was believed
are done in laboratory and take time which may that the oxaliplatin is degraded by chloride
be unacceptable in such surgeries.[38] in complex containing solutions. [45] This view is recently
surgeries like HIPEC continuous measurement being challenged and it has been found to be
of hemoglobin (SpHb) values may facilitate our stable in chloride based solutions. Moreover, these
decision regarding transfusions.[39] Different criteria solutions are readily absorbed from the peritoneal
exist for determining the need to perform a blood cavity and result in fluid overload. The patient
transfusion, among which hemoglobin concentration may develop hyperglycemia due to absorption of
plays a fundamental role. To obtain accurate levels of dextrose containing peritoneal instillate carrier
hemoglobin, analytical methods are traditionally used solution (especially with oxaliplatin). This
that are based on blood samples, which are analyzed hyperglycemia may cause intravascular fluid shift
in a laboratory at intermittent intervals. On occasion, and dilutional hyponatremia which is rapidly
the results from the analyses can take some time and correctable with glycemic correction. The patient
do not show the evolution of the patient between the may develop lactic acidosis mainly due to increased
moment of extraction and when the analytical results glucose metabolism and anaerobic metabolism
are received. In a stressful environment such as that of b. Chemotherapy agents may also lead to dyselectrolytemia.
an operating theatre, these delays and uncertainties Cisplatin causes hypomagnesaemia which leads
mean that some blood transfusions are unnecessary, to cardiac arrhythmias while oxaliplatin causes
especially in cases of stable anemia or perceptible but lactic acidosis, hyperglycemia and hyponatremia.
not very significant blood losses, and can represent Electrolyte disturbances like calcium, potassium and
up to 10% of all transfusions performed magnesium should be replaced if required
b. Various strategies for fluid management have been c. Frequent ABG, and electrolytes (sodium, potassium,
described like “liberal”, “restrictive” or “goal calcium and magnesium) are desired to be measured
directed”. Goal‑directed fluid therapy instead of liberal to detect and manage the abnormalities early.
fluid administration provides better perioperative
results and lesser postoperative complications[33] Postoperative/Critical Care Management
c. The appropriate choice of fluids is debatable. Recent
metaanalysis that showed colloids increase the 1. Management of Hemodynamic: Fluid loss during
adverse events and are not routinely recommended initial 72 hours after surgery may be as high as 4.1
for resuscitation.[40] Colloids replenish intravascular litres per day due to oozing of protein‑rich fluid from
volume in a ratio of 1:1 in a fluid responsive patient the raw surface area due to peritonectomy.[46] Most of
and may be used along with crystalloids to maintain the patients require vasopressors support in the early
‘optovolemia’. In patients with massive ascitic postoperative period to counteract the vasodilatation
drainage the perioperative protein loss may be in due to HIPEC. Postoperative intravenous fluid therapy
range of upto 700 g per day and may necessitate should be guided by hemodynamic changes, urine output
albumin supplementation[41] and losses from drains and nasogastric tube. Blood
d. Urine output: Haemodynamics, hyperthermia and and blood products like fresh frozen plasma should be
use of cytotoxic chemotherapy during HIPEC transfused depending on the drain output, hemoglobin

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 Gupta, et al.: Anesthesia for HIPEC

and hematocrit value, and coagulation profile. The due to hemodynamic instability, diaphragmatic injury or
patient may continue to lose protein rich fluid in the multiple comorbidities preventing safe extubation
exudates and it may lead to decrease in albumin levels 9. Infection control: The infective complications due to
in the postoperative period. So, one should supplement immunosuppression (neutopenia and leucopenia after
Albumin if it falls below 3.0 g/dl to maintain adequate chemotherapy) may be present and the intensivist should
intra vascular volume[47] have a a low threshold to escalate to higher antibiotics if
2. Coagulation profile should be monitored during the required.
postoperative period. The patient may continue to have
thrombocytopenia due to the cytotoxic drugs used and Safety Concerns
dilutional coagulopathy due to massive fluid shift and
blood loss.[48] This coagulation dysfunction peaks at 24 to At high temperature, aerosols and vapours are produced
48 h post surgery with normalization coagulation profile from a chemotherapy drug. The staff involved in HIPEC
in 72 hr.[49] Fresh frozen plasma and platelet should surgery is at risk of inhalation of these aerosols or may get
be transfused to correct any documented coagulation direct contact with chemotherapy due to spillage. This contact
abnormality only and not as routine prophylaxis. TEG and inhalation of chemotherapy may have a deleterious effect
is an important point of care monitor to identify the on the body and the staff should be educated about the
coagulation abnormalities and manage them
handling of chemotherapy. Moreover high risk groups like
3. Electrolyte imbalance due to significant fluid shift
pregnant women, nursing mother, history of abortions, those
during the surgery and immediate postoperative period
planning pregnancy, history of teratogenicity, those with prior
is expected. Therefore they should be measured and
chemotherapy or radiotherapy or immunosuppressive therapy,
replaced periodically
people working with radiotherapy and those with allergic
4. Analgesia: A multimodal analgesia with a combination
reactions to latex/cytotoxic drugs or skin diseases should be
of local anesthetics and opioids in thoracic epidural and
intravenous NSAIDs and opioids provides excellent excluded from the HIPEC team. A mechanism should be in
analgesia. This plays an important role in early place for proper disposal of chemotherapy drug containers
ambulation, early extubation and decrease postoperative and tubings of HIPEC equipment. The national institute
ileus[50] of occupational safety and health has recommended that the
5. Stress Ulcer Prophylaxis: These patients are at risk containers for disposal of chemotherapeutic waste should be
of stress ulcer due to need for mechanical ventilation, leak proof and the labels should clearly mention “cytotoxic
hypotension necessitating vasopressors, non‑steroidal agent”. They should be emptied when half full.[53]
anti‑inflammatory drugs and coagulopathy.[51] So,
all patients should receive prophylactic H2 receptor Conclusion
antagonists or proton pump inhibitors after HIPEC
6. Thromboprophylaxis: Since patients are at risk of Perioperative care of patients undergoing cytoreductive surgery
thrombosis, thromoboprophylaxis with mechanical devices and HIPEC procedure is complex and involves management
like intermittent pneumatic compression and graduated of excessive fluid and protein losses, thermoregulation,
compression stockings should be provided to prevent coagulation disturbance and postoperative care. A higher
DVT.[52] Pharmacological agents like heparin/LMWH PCI is associated with increased duration of surgery, increased
should be started when coagulation profile is normalized blood loss, increased use of vasopressors, increased need of
and bleeding risk is minimal post operative ventilation and coagulation derangements.
7. Feeding/Nutrition: Enteral nutrition is always better than A successful outcome requires a team approach and continuity
parenteral nutrition. Early enteral feeding helps in bowel of care with a vigilant interaction of multiple disciplines. These
movement and reduces translocation of bacteria, thereby patients need extensive prehabilitation and optimization to
decreases infective complications in surgical patients. ensure uneventful smooth intraoperative course and early
Parenteral nutrition need to be given if the patient is recovery and discharge.
unable to take orally due postoperative ileus, stress ulcer
or anastomotic leak Financial support and sponsorship
8. Respiratory support: These patients are hypoxic due Nil.
to ascites, pleural effusion and atelectasis. Although
respiratory parameters improve after CRS due to ascitic Conflicts of interest
drainage, some patients require postoperative ventilation There are no conflicts of interest.

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 Gupta, et al.: Anesthesia for HIPEC

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