What are the discharge instructions for a patient undergoing HIPEC (Hyperthermic Intraperitoneal Chemotherapy) procedure?

Discharge Instructions After HIPEC Procedure

Patients discharged after HIPEC require close monitoring for delayed major complications occurring in 5.7-11% of cases within 90 days, with specific attention to infectious complications, dehydration, bowel obstruction, and anastomotic issues that may necessitate readmission.

Expected Hospital Course and Discharge Timing

• Median hospital stay ranges from 8-24 days, with high-quality trials showing stays of approximately 10 days for HIPEC combined with cytoreductive surgery 1
• Grade 3-4 toxicities occur in approximately 27% of patients during the initial hospitalization, similar to cytoreductive surgery alone 1
• Patients should not be discharged until they demonstrate adequate oral intake, pain control, and stable vital signs 2

Critical Post-Discharge Complications to Monitor

Infectious Complications (Most Common)

• Abdominal abscesses represent 17.6% of delayed complications and are the most common cause of readmission (35% of all readmissions) 3, 4
• Patients should be instructed to monitor for fever, increasing abdominal pain, or purulent drainage from incisions
• Immediate medical evaluation is required for temperature >38.5°C or signs of sepsis 3, 4

Gastrointestinal Complications

• Enterocutaneous fistulae occur in 17.6% of delayed complications, particularly in patients who underwent multivisceral resections 3
• Small bowel obstruction accounts for 17.5% of readmissions and typically presents 2-4 weeks post-discharge 4
• Anastomotic leakage and gastric perforation can present as delayed complications requiring urgent surgical intervention 5
• Patients should report persistent nausea, vomiting, inability to tolerate oral intake, or absence of bowel movements

Genitourinary Complications

• Ureteral strictures with hydronephrosis occur in 17.6% of delayed complications, often presenting weeks after discharge 3, 5
• Monitor for decreased urine output, flank pain, or signs of renal dysfunction
• Creatinine elevation occurs in 15% of patients and requires monitoring 2

Pancreatic Complications

• Pancreatic pseudocyst/pancreatitis represents a significant delayed complication, particularly after extensive upper abdominal cytoreduction 5
• Patients should report severe epigastric pain, persistent nausea, or inability to tolerate oral intake

Wound Complications

• Abdominal wall dehiscence can occur as a delayed complication requiring surgical repair 5
• Instruct patients to report any sensation of "giving way" in the incision or visible separation of wound edges

Readmission Risk Profile

• 7-day readmission rate: 3.5% 4
• 30-day readmission rate: 11% 4
• 90-day delayed complication rate: 5.7-11% 3, 5
• Patients with intraoperative complications have significantly higher readmission rates (p=0.0001) 4
• Mean length of stay for readmission is 11.7 days, with 29.4% requiring reoperation 3

Specific Discharge Instructions

Nausea and Vomiting Management

• Olanzapine 5-10 mg PO daily should be prescribed as first-line agent for breakthrough nausea/vomiting 1
• Alternative agents include lorazepam, metoclopramide, or prochlorperazine 1
• Patients should have prescriptions filled before discharge and clear instructions on when to escalate to combination therapy

Hydration Management

• Dehydration accounts for 14% of readmissions 4
• Patients should be discharged with access to community-based continuing care for IV fluid replacement when oral intake is inadequate 4
• Instruct patients to maintain oral fluid intake of at least 2 liters daily and report signs of dehydration (decreased urine output, dizziness, dry mucous membranes)

Renal Function Monitoring

• Anemia (67% vs 50% in controls) and creatinine elevation (15% vs 4% in controls) are significant complications 2
• Arrange follow-up laboratory testing within 7-10 days of discharge to monitor renal function and hemoglobin
• Patients should report dark urine, decreased urine output, or significant fatigue

Temperature Monitoring

• Patients must monitor temperature twice daily for the first 2 weeks post-discharge 2
• Any fever >38.5°C requires immediate medical evaluation for possible intra-abdominal abscess or anastomotic leak 3, 4

Activity and Wound Care

• Avoid heavy lifting (>10 pounds) for 6-8 weeks to prevent abdominal wall dehiscence 5
• Monitor incisions daily for signs of infection, separation, or drainage
• Report any purulent drainage, increasing redness, or wound separation immediately

Follow-Up Care Coordination

Adjuvant Chemotherapy Planning

• Patients must complete a minimum of 3 cycles (preferably 6 total cycles including neoadjuvant) of systemic chemotherapy 1
• Oncology follow-up should be scheduled within 2-3 weeks of discharge to plan adjuvant therapy timing
• Delayed initiation of adjuvant chemotherapy is expected but should not prevent completion of the full treatment course 1

Surgical Follow-Up

• Schedule surgical follow-up within 2 weeks of discharge for wound assessment and complication screening
• All patients who underwent multivisceral resections require closer monitoring as they are at higher risk for delayed complications 5

Access to Care

• Patients should have 24/7 access to a provider familiar with HIPEC complications, as many patients undergo surgery remotely from their home localities 5
• Provide clear contact information for urgent concerns and establish a low threshold for emergency department evaluation
• Consider telemedicine follow-up for patients living far from the surgical center

Red Flag Symptoms Requiring Immediate Evaluation

Patients should seek immediate medical attention for:

• Fever >38.5°C 3, 4
• Severe or worsening abdominal pain 3, 5
• Persistent vomiting or inability to tolerate oral intake 5, 4
• Absence of bowel movements for >3 days with distension 4
• Purulent or feculent drainage from wounds or drains 3
• Decreased urine output or dark urine 2, 3
• Wound separation or dehiscence 5
• Signs of sepsis (confusion, hypotension, tachycardia) 3, 4

Critical Pitfalls to Avoid

• Do not assume patients are "out of the woods" at discharge—the 90-day complication window extends well beyond initial hospitalization 3, 5
• Do not discharge patients without ensuring access to IV hydration and antibiotics in their community, as these are the most common readmission needs 4
• Do not delay evaluation of concerning symptoms—delayed complications can be life-threatening and require prompt intervention 3, 5
• Mortality from delayed complications is 11.8%, emphasizing the importance of early recognition and treatment 3