What is the recommended fluid management strategy for patients undergoing Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

Goal-Directed Fluid Therapy for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Goal-directed fluid therapy should be implemented during HIPEC procedures to optimize volume status and hemodynamic parameters, aiming for a mildly positive fluid balance of 1-2L by the end of surgery while avoiding fluid overload.

Rationale for Goal-Directed Fluid Therapy in HIPEC

HIPEC procedures present unique hemodynamic challenges due to:

• Extensive cytoreductive surgery with significant fluid shifts
• Increased insensible losses from the open abdomen
• Hyperthermia-induced vasodilation and increased metabolic demands
• Risk of renal injury from chemotherapeutic agents

Pre-HIPEC Phase

• Ensure adequate hydration before surgery
• Avoid prolonged fasting (clear fluids allowed up to 2 hours before surgery) 1
• Use balanced crystalloids (e.g., Ringer's lactate) rather than 0.9% normal saline 1
• Consider baseline volume status and comorbidities that affect fluid tolerance

Intraoperative Fluid Management Protocol

Monitoring Requirements

• Standard ASA monitoring plus:
• Cardiac output monitoring (pulse contour analysis preferred)
• Stroke volume variation (SVV) or pulse pressure variation (PPV)
• Urine output
• Core temperature
• Arterial blood gases and lactate levels

Fluid Administration Strategy

1. Initial Phase (During Cytoreduction)

   • Administer balanced crystalloids at 3-5 ml/kg/hr as maintenance
   • Use SVV/PPV to guide fluid boluses (consider fluid challenge when SVV >10-12%)
   • Target cardiac index 3.0-3.5 L/min/m² 2
   • Maintain mean arterial pressure >65 mmHg

2. HIPEC Phase

   • Anticipate increased fluid requirements due to vasodilation
   • Continue goal-directed approach with fluid boluses based on hemodynamic parameters
   • Consider vasopressors for hypotension despite adequate volume status 1
   • Maintain urine output >0.5 ml/kg/hr during cisplatin perfusion 3

3. Post-HIPEC Phase

   • Reassess volume status after HIPEC completion
   • Adjust fluid administration to achieve a total positive balance of 1-2L by the end of surgery 1
   • Avoid excessive crystalloid administration

Evidence Supporting This Approach

A randomized controlled trial by Colantonio et al. demonstrated that goal-directed fluid therapy during CRS-HIPEC significantly reduced:

• Major abdominal complications (10.5% vs 38.1%)
• Hospital length of stay (19 days vs 29 days)
• Total fluid administration (5.8L vs 8.3L) 4

Another prospective observational study by Pérez-Sánchez et al. confirmed the benefits of individualized goal-directed fluid therapy in maintaining hemodynamic stability throughout all phases of HIPEC surgery 2.

Fluid Type Recommendations

• Preferred: Balanced crystalloids (e.g., Ringer's lactate, Plasma-Lyte)
• Avoid: Routine use of albumin or synthetic colloids 1
• Caution: 0.9% saline may cause hyperchloremic metabolic acidosis 1

Special Considerations

• For patients receiving cisplatin-based HIPEC:

  • Administer furosemide (0.5-1 mg/kg) and mannitol (0.5 g/kg) one hour prior to chemotherapy 3
  • Consider sodium thiosulfate for renal protection 3

• Monitor for and correct:

  • Electrolyte abnormalities (especially potassium)
  • Metabolic acidosis
  • Hyperglycemia

Post-Operative Fluid Management

• Continue goal-directed approach in the immediate post-operative period
• Transition to oral fluids as soon as tolerated
• Discontinue IV fluids when adequate oral intake is established 5
• Monitor for signs of fluid overload or hypovolemia

Common Pitfalls to Avoid

1. Excessive fluid administration leading to:

   • Increased risk of anastomotic leakage
   • Pulmonary complications
   • Prolonged ileus

2. Inadequate fluid resuscitation leading to:

   • Acute kidney injury
   • Poor tissue perfusion
   • Increased risk of thrombotic events

3. Failure to adjust strategy based on individual patient factors:

   • Cardiac function
   • Renal function
   • Extent of peritoneal disease

By implementing this goal-directed fluid therapy protocol during HIPEC procedures, clinicians can optimize hemodynamic parameters, reduce complications, and potentially improve patient outcomes.