- This is a DRAFT Document, dated Nov 11, 2013 by Maine Medical Partners Surgery, and distributed January 2014. Subsequent revisions will be added as they are received.
- Indications, Overview
- Pre Day of Surgery
- Day of Surgery
- Rest of hospital stay
Indications: certain GI Tract cancers and sarcomas with peritoneal carcinomatosis
- Laparotomy, with complete removal of large tumor masses, and resection of all involved non-essential organs (e.g., omentum, spleen)
- 90 Minute intraperitoneal perfusion with hyperthermic chemotherapy (41 deg C) (usually mitomycin C)
- Closure and Treatment of subsequent metabolic acidemia
Preop: Patients usually present with one or several of the following:
- prior abdominal surgery
- may have other significant system problems: renal, cardiac, pulmonary
Patient will go to MMC-designated pre-op facility to meet with anesthesia with attention to the following:
- review of consultant records and preop eval (e.g. cardiology, pulmonary,etc...)
- discussion about baseline pain control needs and expected plan for postop pain control
- preop labs to include NEW type and screen and coagulation panel
Patient orders in ASU will include:
- heparin sq and venodynes
- normal saline at 100 cc/hr
- cefotetan 2 gm to be adjusted for weight
- epidural (for post op pain management) order
- Central line need to be determined by surgery team and anesthesia staff based on patient access given that most have received preoperative chemotherapy with limited access or mediport only
- Arterial line
Long cases with significant Fluid shifts:
- -blood loss (moderate)
- -third space loss (essentially an intraperitoneal burn) (massive)
- -vasodilation due to heating
Intraop focus does not require fluid restriction given intraperitoneal heating to 41 degrees Celsius.
The patient should receive appropriate fluid to maintain urine output of at least 40 cc/hr or by weight.
The perfusion cycle is 90 minutes at a goal temperature of 41 degrees Celsius.
There is no systemic toxicity from 40 mg mitomycin C.
It is best to keep patient core temperature below 39 degrees to avoid seizure and Heat Stroke
There is significant metabolic acidemia after hyperthermic perfusion
-Urine Output*: monitor q 15' during hyperthermia
-Bair Hugger: ambient air only during hyperthermia (no heating)
-Availability of cranial ice packs & cold saline peritoneal lavage in the event of heat stroke syndrome
-Treatment of metabolic acidemia with NaHCO3
PACU managment again revolves around fluid resuscitation.
Some patients may require ventilation postop.
The patients will transfer to COR or Gibson depending on comorbid risk and baseline performance status. Pain control again will be managed by pain service with epidural, narcotic and/or toradol.
The patients will have the following per protocol:
a. NG to low constant suction
b. foley catheter
c. possible vac dressing
*All patient body fluids after chemotherapy should be considered contaminated for 48 hrs after chemotherapy. Be sure to empty urinemeter BEFORE the start of chemotherapy, as all subsequent urine must be considered a biohazard and disposed of properly.
1 Stephens, White, Esquival, Stuart, Sugarbaker: www.surgicaloncology.com/hiicman.htm