This document provides information on perioperative management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). It discusses physiological changes during HIPEC including increased heart rate and venous pressure, decreased tissue oxygenation, and coagulopathy. It outlines selection criteria for CRS/HIPEC and important preoperative assessments. Intraoperatively, there are massive fluid shifts, blood loss, electrolyte imbalances, and temperature regulation challenges. Postoperatively, complications can include hypovolemia, bowel issues, bleeding, and infections. Close monitoring of fluids, hemodynamics, coagulation, nutrition, and other parameters is important for critical care management after CRS/H
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
The prognosis of most peritoneal surface malignancies were previously dismal. However, with the incorporation of HIPEC to standard of care, we have been seeing doubling of survival for select malignancies. Appropriate patient selection is crucial.
Anaesthetic considerations for Robotic Surgery, What to expect, how to go ahead. An update and incite on the intricacies of Robotic Surgery and Anaesthetic implications.
Update on regional anesthesia for breast surgery - Michael Herrick - SSAI2017scanFOAM
A talk by Michael Herrick at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
The prognosis of most peritoneal surface malignancies were previously dismal. However, with the incorporation of HIPEC to standard of care, we have been seeing doubling of survival for select malignancies. Appropriate patient selection is crucial.
Anaesthetic considerations for Robotic Surgery, What to expect, how to go ahead. An update and incite on the intricacies of Robotic Surgery and Anaesthetic implications.
Update on regional anesthesia for breast surgery - Michael Herrick - SSAI2017scanFOAM
A talk by Michael Herrick at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
The tumescent liposuction procedure involves the use of lidocaine (a local anesthetic), epinephrine (a hormone and a neurotransmitter that shrinks blood vessels and minimizes bleeding), and a saline solution that is injected into the treatment area. The fluid causes the fat and skin to swell up, making it easier to suction out excess fatty cells.
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
The tumescent liposuction procedure involves the use of lidocaine (a local anesthetic), epinephrine (a hormone and a neurotransmitter that shrinks blood vessels and minimizes bleeding), and a saline solution that is injected into the treatment area. The fluid causes the fat and skin to swell up, making it easier to suction out excess fatty cells.
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
Anaethetic Management of Obstetric Haemorrhage.pptxBiltonbhawal
Obstetric hemorrhage is a major cause of mortality and morbidity of pregnant lady all over the world. Management of MOH is very critical if we are not prepared to face the problem in advance.Adequate preparation and careful management may enhance better outcome.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. Presentation includes short notes about
• Physiological changes during HIPEC
• Patient selection criteria for HIPEC and
Cytoreductive Surgery (CRS)
• Preoperative concerns
• Severe fluid shift
• HIPEC and electrolyte balance
• Hemodynamic management
• Control of body temperature
• Postoperative complications
• Postoperative/critical care management
• Conclusion
3. PHYSIOLOGICAL CHANGES DURING
HIPEC
• Cardiovascular: Increase in heart rate and
central venous pressure. No significant
changes in blood pressure.
• Respiratory: Increase in peak airway pressures
up to 30 mmHg.
Decrease in tissue oxygenation.
Increase in end-tidal CO2 levels.
4. PHYSIOLOGICAL CHANGES DURING
HIPEC
• Renal: Decreased perfusion to the kidneys.
Metabolic acidosis with increased lactate.
• Coagulation: Hyperthermia-associated
coagulopathy with a decrease in platelet
count (Thrombocytopenia)
as well as an increase in Prothrombin Time (PT)
and International Normalized Ratio (INR).
(Coagulopathy is corrected on the 5th PO day).
5. Selection Criteria for HIPEC and
Cyto Reductive Surgery
• Medical optimization with no active cardiac or
respiratory conditions.
• Absence of extra abdominal disease, extensive
hepatic metastases, and significant retroperitoneal
disease.
• Age less than 70 years , however not
absolutely indicated.
• Peritoneal disease that is amenable to complete or
near complete resection.
6. • It is imperative to perform a detailed
preoperative assessment to avoid ORGAN
FAILURE that may occur in some patients.
• Operative risk assessment for comorbidities
like diabetes, hypertension and
heart disease.
• Assessment of pulmonary system.
7. Preoperative Concerns
• AGAIN Thorough assessment of the
patient’s cardiac and pulmonary systems
is essential to assess their ability to
respond to the physiological challenges
faced intraoperatively .
8. PREOPERATIVE WORKUP
• Most patients for elective major abdominal surgery
invariably undergo adequate preoperative assessment
and evaluation.
• Echocardiography and dynamic cardiac assessments
• Full blood count
• Coagulation studies
• Electrolytes, urea and creatinine levels
• Review the nutritional status of the patient and to
measure a preoperative albumin level
• Glomerular filtration rate to identify patients at risk of
an acute kidney injury associated with the HIPEC
9. PREOPERATIVE WORKUP
Preoperative SERUM ALBUMIN deserves
a special mentioning .
• It reflects the nutritional status of the patient.
• Albumin levels strongly predicts length of hospital
stay and overall survival.
• Malnutrition may be present in >50% of patients with
ovarian cancer and advanced colorectal cancer with
peritoneal metastasis.
• Preoperative correction of anemia and
hypoalbuminemia is preferable.
11. OF HIPEC and CRS
PERIOPERATIVE CONCERNS
OF HIPEC and CRS
Perioperative management is complex
and is associated with :
• Massive fluid shift
• Blood loss
• Temperature imbalance
• Hemodynamic alterations
And
• Renal toxicity of chemotherapeutic drugs
12. Chemotherapeutics used during hyperthermic
intraperitoneal chemotherapy and possible
chemotherapeutic-specific adverse effects
Mitomycin C: Nephrotoxicity, pulmotoxicity
Cisplatin Peripheral neuropathia, myelotoxicity
Cisplatin : Peripheral neuropathia, myelotoxicity
Doxorubicin : Cardiotoxicity (arrhythmia,
cardiomyopathy), myelotoxicity
Oxyliplatin : Neurotoxicity (laryngeal/pharyngeal
dysesthesia)
Irinotecan : Myelotoxicity
13. MASSIVE FLUID SHIFT
• Significant blood loss associated with the
major debulking surgery.
• Evaporative losses related to the
open abdomen.
• Ascites drainage of protein‐rich fluid.
• HIPEC causes peritoneal inflammation
that can cause perioperative fluid loss.
14. MASSIVE FLUID SHIFT
• Intraoperative fluid losses may be as high
as 12-20 ml/kg/hour depending on the
degree of debulking i.e. 1800 ml/hour.
• Large amount of fluid shift occurs during
cytoreductive phase due to large raw surface
produced by peritonectomy, ascitic drainage
and significant blood loss during this procedure .
15. MASSIVE FLUID SHIFT
• Anesthesiologists need to manage intravenous
fluid therapy, blood transfusion and electrolyte
balance to maintain optimal end-organ
perfusion and prevent renal injury.
• Patients with poor cardiac reserve may not
tolerate a high volume of intravenous fluid and
may require vasopressors and inotropes to be
used carefully .
16. MASSIVE FLUID SHIFT
• Fluid replacement is with crystalloid or colloid
solutions as well as blood and plasma .
• Up to NINE LITERS of blood loss has been
reported during Cytoreduction Surgery (CRS)
and HIPEC due to surgical reasons and
coagulation abnormalities.
17. RENAL PROTECTION
• The best way to preserve renal function is to
maintain NORMOVOLEMIA and
ADEQUATE URINARY OUTPUT
(1mL/kg/h).
NO diuretics or dopamine is recommended.
18. HIPEC AND ELECTROLYTE
BALANCE
• Chemotherapeutic agents (especially if dissolved
in DW5%) may lead to:
• Dilutional Hyponatremia ( serum sodium ) ( ? Mechanism)
• Lactic acidosis mainly due to increased
glucose metabolism and anaerobic metabolism.
• Hypomagnesaemia which leads to cardiac
arrhythmias .
• Electrolyte disturbances like calcium, potassium
and magnesium should be replaced if required.
19. HIPEC AND ELECTROLYTE
BALANCE
Frequent ABG,
and electrolytes
(sodium,
potassium,
calcium and
magnesium)
are desired to
be measured
calcium and
magnesium)
are desired to
be measured
to detect and
manage the
abnormalities
early.
to detect and
manage the
abnormalities
early.
20. Hemodynamic Management
• Hyperthermia during HIPEC leads to peripheral
vasodilatation and reduction in peripheral
vascular resistance and mean arterial pressure .
• There is an increase in heart rate in order to
maintain cardiac output .
• An arterial line, a central venous catheter and
a urinary catheter are useful for monitoring the
hemodynamic status of the patient in real time .
21. CONTROL OF BODY
TEMPERATURE
• CRS combined with HIPEC can be associated
with both hypothermia and hyperthermia.
• Hypothermia occurs during CRS and increases
the risk of blood loss and surgical wound
infections.
• Hyperthermia: The carrier solution for HIPEC
is heated to 42C-43C and body temperature
may rise to up to 40.5 C. (? Effects on abdominal organs)
22. CONTROL OF BODY
TEMPERATURE
• Hyperthermia increases the systemic oxygen
demand, and may lead to an increased
metabolic demand levels and a concomitant
metabolic acidosis AKI.
• Hyperthermia also puts the patient at risk of
coagulopathies, liver dysfunction,
neuropathies, and seizures.
23. CONTROL OF BODY
TEMPERATURE
• Body temperature is monitored by two probes.
• One temperature probe is placed in the
esophagus/nasopharynx for core temperature
monitoring and the temperature of the abdominal
cavity is measured by thermistors present in the
inlet and outlet drains of the HIPEC machine.
• Thermoregulation plays a significant role in
maintaining the metabolic homeostasis,
coagulation, anti‐inflammatory cascade and
neurological status intact .
24. CONTROL OF BODY
TEMPERATURE
• Warming during CRS to prevent hypothermia
and to prevent coagulation and metabolic
harmful effects .
AND
• During the HIPEC phase, cooling blankets and
cold head-wraps or cooling blocks can be used
to help to regulate the temperature.
25. CONTROL OF BODY
TEMPERATURE
• Cold intravenous fluids and placement of
ice packs in the axillae of the patient may
be required to normalize the temperature .
• If despite all these measures, core body
temperature rises to ≥39°C then the
perfusionist should be advised to reduce the
instillate temperature .
26. Postoperative Complications
Hypovolemia/Hypoproteinemia as the patient loses
4 – 5 liters of PROTEIN – ENRICHED fluid per day.
Bowel
perforation
Anastomotic
and bile leakage
Fistula formation
Postoperative
bleeding or
infections
Venous‐thromboembolic
complications
Postoperative ileus
Complications related to
chemotherapy as leukopenia
28. Postoperative/Critical Care
Management
• Postoperative fluid loss during the first 72 hours following surgery
is still very high with values up to 4 liters per day, whereas most of the
fluid loss occurs via abdominal drains (40%) due to the severely
wounded surface .
• Protein loss is remarkable with decreased albumin levels starting to
decline during surgery with the frequent need for exogenous
administration . Supplement Albumin if it falls below 3.0 g/dl
to maintain adequate intra vascular volume.
• Close monitoring of fluid loss and turnover is of critical
importance for the patient’s convalescence.
REFERENCES :
1.Arakelian E, Gunningberg L, Larsson J, et al. Factors influencing early postoperative recovery after
cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2011; 37:897–903.
2. Cooksley TJ, Haji‐Michael P. Postoperative critical care management of patients undergoing cytoreductive
surgery and Heated Intraperiton al Chemotherapy (HIPEC). World J Surg Oncol 2011; 9:169
29. Postoperative/Critical Care
Management
• Vasodilation may occur after HIPEC.
• Vasopressors for patients who are not fluid
responsive to avoid fluid overload.
• Early enteral feeding is recommended,
as nutrition is crucial to promote wound
healing and improve intestinal health.
30. Postoperative/Critical Care
Management
• Maintain an adequate effective circulating volume by
supplying sufficient intravenous fluids such as crystalloid &
colloid solutions or blood and blood products like fresh frozen
plasma.
• ANALGEIA .There is increasing evidence that thoracic
epidural anesthesia (TEA) with local anesthetics and
opioids is superior in the control of dynamic pain, playing a
key role in early extubation and mobilization and reducing
postoperative pulmonary complications.
• TEA Hypotension & Epidural hematoma ?
• Multimodal analgesia is a good alternative.
31. Postoperative/Critical Care
Management
• Postoperative respiratory support is not always necessary.
It was reported that all the patients were extubated
in the OR .
• The coagulation profile takes at least 5 days
to get back to baseline, eventual transfusions are needed .
• Patients with gross ascites often lose in excess of two litters
of ascitic fluid rich in protein (0.5–4 g/dL) which is
primarily albumin.
• Renal Status, Electrolyte Balance, Glycemic Control :
Impairment to these functions is reported to be short lasting.
Standard care is needed.
• Stress Ulcer Prophylaxis.
• Infection Control .
32. Postoperative Care
• Postoperative ileus is a common problem after
CRS and HIPEC.
• Oral intake, regaining bowel functions and mobilization
usually occur between 7 and 11 days postoperatively.
• Patients may experience nausea for up to 13 days
postoperatively.
• Early enteral feeding is both safe and beneficial for
these patients.
• Epidural anesthesia has been recommended by some
as a strategy to reduce postoperative ileus .
Arakelian E, Gunningberg L, Larsson J, Norlén K, Mahteme H.
Factors influencing early postoperative recovery after cytoreductive
surgery and hyperthermic intraperitoneal chemotherapy.
Eur J Surg Oncol 2011;37:897–903
33. Postoperative Care
• Anti-emetic prophylaxis using 5-HT3
antagonists should continue for a few
days at a regular intervals.
• Maintaining Hemoglobin concentration
between 8-10 g/dL according to CV risk.
• Avoid nephrotoxic medications and diuresis
should not fall below 1 mL/kg/hour.
• Hemodynamic monitoring until the third
postoperative day or discharge from ICU.
34. Postoperative Care
• Drain Management Enhancing early
mobilization is an essential element of postoperative
enhanced recovery protocols.
• Tubes and drains carry the risks of infection and can
hinder mobility and cause pain.
• Drains should be removed as early as possible.
• It is recommended to leave only one abdominal
silicone drain for the pelvis, additional drains can
be used especially after splenectomy or (partial)
gastrectomy.
35. Postoperative Care
• Management of Hemodynamics:
REMEMBER that Fluid loss during initial
72 hours after surgery may be as high as
4 liters per day due to oozing of protein-rich
fluid from the raw surface area due to
peritonectomy .
• Most of the patients require vasopressor
support in the early postoperative period to
counteract the vasodilatation due to HIPEC.
36. VASOPRESSOR SUPPORT
In our case of HIPEC operated on Monday
14th of June 2021 at Ismailia Oncology Teaching
Hospital, we have supported the patient`s
circulation by Noradrenaline (Levophed)
vasopressor , Starting with a dose of
0.05 microgram/kg/minute (that is 210 mic/hour)
and raised gradually to 400 mic/hour to
support the circulation and maintain B.P.
37.
38. One mL contains 80 microgram Noradrenaline (Levophed)
Starting dose for a 70 kg patient is :
0.025 mic. x 70 kg x 60 min = 105 microgram/hour = 105/80 =
1.3 mL/hour . To be increased gradually according to patient`s response.
NORADRENALINE INFUSION (Levophed)
4 mg ampoule = 4 mL 0f 1:1000
Add 4 mL of 1:1000 Noradrenaline to 46 mL
Glucose to make 50 mL.
Starting dose : 0.025 – 0.05 microgram/kg/min.
The rate in infusion/syringe pump in mL/hour.
39. CONCLUSION
Perioperative care of patients undergoing cytoreductive surgery
and HIPEC procedure is complex and involves management of
excessive fluid and protein losses, thermoregulation,
coagulation disturbance and postoperative care.
40. • Gupta, et al.: Anesthesia for HIPEC
Journal of Anaesthesiology Clinical Pharmacology | Volume 35 |
Issue 1 | January-March 2019.
• Anesthesia tutorial of the week.
General anesthesia 379
Dr Rosemarie Kearsley, Dr Sine´ ad Egan, Professor Conan McCaul
Anesthesia for cytoreductive surgery with hyperthermic
intraperitoneal chemotherapy (HIPEC) (15 May 2019)
41. 1. Neuwirth MG, Alexander HR, Karakousis GC. Then and now: cytoreductive surgery with hyperthermic intraperitoneal
chemotherapy (HIPEC), a historical perspective. J Gastrointest Oncol. 2016;7(1):18-28.
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