Health care providers administering treatment in the operating room have to deal with a variety of occupational health risks on a daily basis such as exposure to HIV, hepatitis, any infectious process, tuberculosis, exposure to intraoperative X-rays and accidental inhalation of anesthetics. Currently, there are growing concerns about risks associated with exposure to cytotoxic agents. With the potential use of intraoperative chemotherapy, apprehensions have been expressed regarding the cumulative, long term effects of low dose daily exposure. Research protocols currently in place focus on understanding potential toxic side effects of chemotherapy drugs at therapeutic levels. Conventional policies that have been implemented for occupational exposure are based on the assumption that low dose, cumulative exposure may lead to toxic manifestations. Institutional policies should primarily focus on the safety of the patient, health care providers and the environment.
Anesthesiology for HIIC Administration and Cytoreductive Surgery
Hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) is initialized after major abdominal procedures that may have resulted in moderate blood loss, plasma electrolyte changes, massive fluid shifts, and changes in coagulation parameters. In cytoreductive surgeries, the anesthesia care team should pay special attention while correcting electrolyte changes, replacing fluids and initializing other therapies based on laboratory results (hemoglobin, ABG, sodium, glucose, lactate, potassium and calcium). A prothrombin time (PT) and a partial prothrombin time (PTT) are evaluated while the surgeons prepare for the heated chemotherapy procedure. Prior to the procedure, the patient’s blood is examined and if abnormalities are found, they are corrected immediately.
During the preliminary stage of HIIC procedure, the anesthesia team evaluates the standard support and monitoring equipment. To avoid heart related complications during the perfusion process, specific prophylactic procedures may be initiated. These may involve covering the foam padding with a warming blanket, using the smoke evacuator system at a higher setting, and appropriate patient hydration. When the chemotherapy procedure is finally initiated, all patient warming systems are switched off; the operating room is cooled at optimal levels, and ambient air is blown over the patient using the upper body Bair hugger. An intravenous drip with Pavulon, Sufenta and Versed is administered for paralysis. Actual dosage of these drugs can be reduced during HIIC since simulation is minimal during the procedure.
Maintaining patient hydration at appropriate levels is mandatory prior to the initialization of the HIIC perfusion. Reports indicate that the patient’s peripheral vasodilatation is one of the major complications that can occur during HIIC procedures. Symptoms that are indicative of this medical complication include decreased urine output, followed by hypotension and tachycardia. The anesthesiologist and the perfusionist should be vigilant of the “heat stroke syndrome” and be prepared to implement standard procedures required for correcting the problem. If heat stroke symptoms are not corrected immediately, the patient’s core temperature (esophageal temperature) may keep increasing even when the surgeons might have removed the heated perfusate. Administering cool saline in the abdominopelvic cavity and placing ice around the patient’s head may be necessary for alleviating heat stroke symptoms. The patient’s urine output was monitored by the anesthesiologist during the HIIC perfusion. Based on the anesthesiologist’s prescription, furosemide, renal dose dopamine or mannitol were administered to maintain minimum 400 cc every hour during the 90 minute HIIC perfusion and for one hour after the procedure.
Administering Hespan is strongly contraindicated for patient’s receiving
a peritoneal stripping treatment. A chemically modified complex polysaccharide,
Hetastarch has a molecular weight of approximately 4.5 x 105
daltons. It has been reported that hetastarch can lead to coagulopathy
through 3 different mechanisms. Firstly, hetastarch adversely affects
blood clots, reducing their stability, which accelerates the conversion
of fibrinogen to fibrin. Secondly, hetastarch macromolecules lead to the
coating of the platelet outer membrane, which reduces adhesiveness and
increases bleeding time. Thirdly, the macromolecules may result in acquired
Von Willebrand’s syndrome, characterized by reduced levels of factor VIII
activity. Seven patients who had undergone this surgical oncology experienced
coagulopathies, attributable to hetastarch macromolecules. Two of those
seven patients, who underwent cytoreductive surgery with HIIC, have been
included for the purpose of the above analysis. Use of hetastarch has
been discontinued for all patients who may have been prescribed a peritonectomy
treatment.
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