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Microvascular Dysfunction

Is there any difference between general anesthesia alone or associated with thoracic epidural anaesthesia on thenar StO₂ along hyperthermia for intraperitoneal chemotherapy?

Dagois S, Damoisel C, Lukaszewicz AC, Vostroknoutova I, Gevorgyan H, Luengo C, Pocard M, Payen D. Int Care Med. 2009;35(Suppl 1):S155.

Introduction: Hyperthermic intraperitoneal chemotherapy (HIPEC), associated with cytoreductive surgery is the only therapy prolonging survival for patients with peritoneal carcinomatosis.

Objective: To evaluate the impact of transient acute hyperthermia on systemic hemodynamic and micro-oxygenation of thenar eminence under general anaesthesia (GA) alone or associated with thoracic epidural anaesthesia (TEA).

Material and Methods: 15 patients, ASA1 or 2, 9F/6 M, 50.3 y.o. (33–66), with peritoneal carcinomatosis; GA alone (n = 6) or associated to TEA (n = 9, T8–T9, ropivacaïne 2 mg/ml + sufentanyl 0.5 mcg/ml) settled before induction. Monitoring: invasive blood pressure (BP, radial artery), BIS (30–40, Astect Medical System^®), oesophageal temperature (Tyco Healthcare^®), continuous central SvO₂ measurement (Edwards Lifesciences^®), cardiac output (CO, Doppler TE, Doptek^®). Muscle haemoglobin saturation measurements (StO₂, thenar eminence, non-blocking area) by NIRS (Hutchinson^®) and during occlusion test (3 min, 300 mmHg). Blood flow monitored on forearm by laser-Doppler (LD, Transonic^®). Timing of measurements: end of viscerolysis, beginning and end of chemohyperthermia, and finally at the end of the procedure. Statistics: nonparametric tests

Results: Procedure duration: 11.1 h (8–14) with a large fluid loading (20 ml/kg per hour, range 9–35) with crystalloids (1/3 0.9% saline, 2/3 ringer lactate), comparable in both groups. The two groups did not differ for systemic hemodynamic. Hyperthermia induced a moderate tachycardia similar under GA or GA + TEA. BP decreased at the end of the procedure, with a stable CO. Oesophageal temperature increased with hyperthermia, more importantly in the GA group (p = 0.03). Baseline StO₂ was in normal range and stable in the two groups. The StO₂-reperfusion slope did not differ between GA and TEA and increase during hyperthermia. The more rapid was the drop of occlusion slope (rapid ischemia), the steeper was the reperfusion slope (vascular recruitment). The forearm skin blood flow (laser-Doppler) increased with hyperthermia so did the LD-reperfusion slope, with no difference in the two groups.

Discussion: We have found no difference between GA or TEA + GA for the consequences of hyperthermia on systemic and tissue perfusion during hypothermic intraperitoneal chemotherapy. The benefit of one of two anaesthetic procedures remains to be demonstrated in postoperative period especially for inflammatory parameters.