What care is required for a patient post Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

Post-HIPEC Care Essentials

Healthcare providers caring for patients immediately after HIPEC must anticipate metabolic acidosis, hepatotoxicity, coagulopathy, and significant fluid shifts requiring intensive monitoring for at least 48 hours, with most patients needing minimal organ support if properly selected. 1, 2, 3

Critical Care Monitoring Requirements

Initial 24-48 Hour Period

• All patients require Critical Care Unit admission for continuous monitoring for a minimum of 48 hours, even if extubated in the operating room 3
• Expect median CCU stay of 2.4 days (range 0.8-7.8 days) 3
• Monitor for metabolic acidosis that develops during HIPEC and persists through the first postoperative day, manifesting as decreased pH and base excess 4
• Anticipate hyperthermia at procedure completion that may persist into early postoperative period 4

Cardiovascular Management

• Approximately 26% of patients require vasopressor support with norepinephrine 3
• Mean duration of vasopressor need is 13.94 hours (range 5-51 hours) at mean dose of 0.04 mcg/kg/min 3
• Monitor for significant fluid shifts and maintain adequate intravascular volume given the physiological changes from heated chemotherapy perfusion 3, 5

Respiratory Considerations

• Early extubation in the operating room is safe and efficacious with epidural analgesia 3
• The majority of patients (70.1%) do not require postoperative organ support 3
• Atelectasis and pleural effusion are common radiological findings but rarely affect recovery unless extensive (grade 3 or higher) 6
• Only 2.9% of patients require respiratory support, typically for pneumonia 3
• Thoracocentesis or chest tube placement may be needed in approximately 16% of patients but does not significantly delay recovery 6

Metabolic and Laboratory Monitoring

Hepatotoxicity Surveillance

• Toxic liver damage is the most frequent complication after HIPEC, occurring significantly more often than after standard cytoreductive surgery alone 4
• Monitor alanine transaminase (ALT) and aspartate transaminase (AST) levels closely, as statistically significant elevations develop by end of first postoperative day 4
• Hepatotoxicity signs persist beyond metabolic acidosis resolution and require ongoing monitoring 4

Coagulation Management

• Post-operative coagulopathy peaks at 24 hours and requires serial monitoring 3
• Anticipate need for correction of coagulation parameters during this critical window 3

Electrolyte and Metabolic Abnormalities

• Expect hyperglycemia, lactic acidosis, and hypokalemia during and immediately after HIPEC 5
• Continuous monitoring with proactive correction of electrolyte derangements is imperative to decrease morbidity 5
• Significant drop in serum albumin occurs postoperatively and should be anticipated 3

Temperature Management

• Close attention to temperature control is essential, as hyperthermia from the 41-43°C perfusate persists into early recovery 5, 4

Renal Protection and Fluid Management

For Cisplatin-Based HIPEC (Standard Agent at 100 mg/m²)

• Ensure adequate diuresis was established with furosemide and mannitol administered one hour prior to chemotherapy 1, 5
• Verify sodium thiosulfate was considered for renal protection 5
• Monitor urine output closely, as high platinum concentrations persist in urine for 3 days post-procedure (median 1260 ng/ml day 1, decreasing to 413 ng/ml by day 3) 7

Chemotherapy Safety and Contamination Control

Surface Contamination Management

• High platinum-drug concentrations in urine and drainage fluids are the main source of environmental contamination for 3 days post-HIPEC 7
• Outer surfaces of urine bags show highest contamination (median 2.77 pg/cm²) 7
• Healthcare workers must use chemotherapy-certified personal protective equipment (PPE) when handling urine bags, drainage bags, and patient care areas 7, 5
• Floor contamination occurs (median 0.14-0.24 pg/cm²), requiring appropriate cleaning protocols 7
• Safe handling of urine and drainage liquids is the best way to avoid cross-contamination in ICUs and wards 7

Drainage Fluid Monitoring

• Platinum concentrations in drainage fluids are generally lower than urine but still require precautions 7
• Drainage bag surfaces show median contamination of 0.22 pg/cm² 7

Antiemetic Management

Post-HIPEC Nausea and Vomiting Prevention

• Multi-agent pre-medication protocols should have been administered prior to HIPEC infusion to reduce post-operative nausea and vomiting 5
• For breakthrough nausea/vomiting, add olanzapine 5-10 mg PO daily (category 1 recommendation) as first-line agent from different drug class 8
• Alternative breakthrough agents include lorazepam 0.5-2 mg every 6 hours, metoclopramide 10-20 mg every 4-6 hours, or prochlorperazine 10 mg every 6 hours 8

Expected Hospital Course

Length of Stay

• Median hospital stay ranges from 8-24 days, though high-quality trials show minimal difference compared to cytoreductive surgery alone (median 10 vs 8 days in M06OVH-OVHIPEC trial) 8, 2
• The procedure time of 300-600 minutes significantly exceeds standard cytoreductive surgery, contributing to physiological stress 1, 2

Complication Rates

• Major/severe complications occur in 9-40% of patients within 30 days, with significant variation across centers 1, 2
• Grade 3-4 toxicities occur in approximately 27% of patients, similar to cytoreductive surgery alone 8
• Perioperative mortality is 0% in recent high-quality studies when performed at experienced centers with appropriate patient selection 2

Timing of Adjuvant Chemotherapy

Delayed Initiation Expected

• Adjuvant chemotherapy initiation is significantly delayed after HIPEC compared to standard surgery (mean 31.9 ± 4.4 days vs 18.6 ± 1.6 days) 4
• This delay is associated with longer restoration period for organ function, particularly liver function 4
• Despite delay, patients must complete minimum of 3 cycles (preferably 6 total cycles including neoadjuvant) of systemic chemotherapy per NCCN guidelines 8, 1

Critical Pitfalls to Avoid

Patient Selection Verification

• Confirm the patient received HIPEC only after neoadjuvant chemotherapy and interval debulking surgery, not after primary debulking surgery, as the latter shows no survival benefit 8, 1
• Verify complete cytoreduction (R0 resection) was achieved, as residual disease negates HIPEC benefits 1, 2

Monitoring Gaps

• Do not discharge from Critical Care before 48 hours given the post-operative metabolic and physiological challenges 3
• Do not underestimate hepatotoxicity risk—this is the most frequent complication and requires serial monitoring beyond the first 24 hours 4
• Do not neglect chemotherapy safety protocols for the full 3-day period when platinum concentrations remain elevated in body fluids 7