What are the best practices for using vasoactive drugs during Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

Best Practices for Vasoactive Drugs During HIPEC

Norepinephrine should be used as the first-line vasopressor during Hyperthermic Intraperitoneal Chemotherapy (HIPEC) procedures to maintain hemodynamic stability and adequate tissue perfusion with a target mean arterial pressure (MAP) of 65 mmHg.

Hemodynamic Challenges During HIPEC

HIPEC presents unique hemodynamic challenges due to several factors:

• Hyperthermia (41-43°C) causing vasodilation
• Large fluid shifts during peritoneal lavage
• Potential for third-spacing of fluids
• Systemic absorption of chemotherapy agents
• Extended surgical duration (300-600 minutes median) 1

Vasoactive Management Algorithm for HIPEC

First-Line Approach

1. Norepinephrine (0.1-0.5 mcg/kg/min)
   • Preferred first-line agent for maintaining adequate tissue perfusion 2
   • Effectively treats severe hypotension and low peripheral resistance common during HIPEC
   • Should be administered through a central line to prevent tissue necrosis from extravasation 2

Second-Line Options (if norepinephrine insufficient)

1. Add vasopressin (up to 0.03 U/min)

   • Can be added to norepinephrine to raise MAP or decrease norepinephrine dosage 2
   • Particularly useful when high doses of norepinephrine are required

2. Add epinephrine (0.1-0.5 mcg/kg/min)

   • Consider when additional inotropic support is needed alongside vasopressor effect 2
   • Useful for patients with concurrent myocardial depression

Third-Line Options

1. Phenylephrine (0.5-2.0 mcg/kg/min)

   • Consider in patients with tachyarrhythmias where norepinephrine may be problematic 2
   • Pure alpha-adrenergic agent with less chronotropic effects

2. Dopamine (5-10 mcg/kg/min)

   • Should only be used in highly selected patients with low risk of tachyarrhythmias or with bradycardia 2
   • Not recommended as first-line therapy due to higher risk of arrhythmias

Hemodynamic Targets and Monitoring

• Target MAP: Maintain at 65 mmHg to ensure adequate tissue perfusion 2
• Monitoring: Continuous arterial pressure monitoring is essential
• Additional parameters: Monitor cardiac output, mixed venous oxygen saturation, lactate clearance, and urine output to assess adequacy of tissue perfusion 2

Special Considerations During HIPEC

• Fluid Management: Ensure adequate volume status before initiating vasopressors, but avoid excessive fluid administration which may worsen third-spacing
• Temperature Effects: Account for vasodilation from hyperthermia (41-43°C) when titrating vasopressors
• Chemotherapy Agents: Be aware of potential cardiac effects of specific chemotherapy agents used during HIPEC (particularly cisplatin) 2
• Renal Protection: Monitor urine output closely as both vasopressors and chemotherapy agents can affect renal function

Common Pitfalls to Avoid

1. Overreliance on fluid resuscitation - May worsen third-spacing and dilute coagulation factors
2. Delayed initiation of vasopressors - Should be started promptly when hypotension persists despite adequate volume status
3. Fixed vasopressor dosing - Always titrate to effect rather than using fixed doses 2
4. Ignoring underlying cardiac dysfunction - Consider adding inotropic support (dobutamine) if evidence of myocardial depression
5. Failure to monitor for extravasation - Administer vasopressors through central lines and monitor infusion sites regularly 2

By following this evidence-based approach to vasoactive management during HIPEC, clinicians can maintain adequate tissue perfusion while minimizing complications, potentially improving patient outcomes in terms of morbidity and mortality.