Anaesthetic Management of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery (CRS) and HIPEC entail extensive surgery for removing the macroscopic disease followed by instillation of chemotherapy at high temperature inside the peritoneal cavity to eliminate the residual microscopic disease. Intraperitoneal administration of heated chemotherapy achieves a pharmacokinetic advantage by obtaining high local concentrations while maintaining low systemic drug levels. It also leads to increased penetration of the drug and increased destruction of tumour cells. Both CRS and HIPEC phases are marked by different physiological changes which require appropriate management strategies. On one hand, the CRS phase is marked by blood loss, fluid shifts, tissue manipulation and hypothermia, whereas the HIPEC phase may be marred by cytotoxic effects of chemotherapy, inflammation, hyperthermia and nephropathy. Advanced hemodynamic monitoring is essential to manage fluid and hemodynamic changes and aggressive temperature management is essential to maintain normothermia. Postoperative phase requires management of dyselectrolytemia, coagulopathy, fluid shifts and analgesia. Prehabilitation, maintenance of hemodynamic and fluid shifts and good analgesia and early ambulation, etc. play a role in achieving better patient outcomes.