Please see Bibliography of References for a list of abstracts, manuscripts and posters.
Dagois S, Caragliano G, Heyer L, Vostroknoutova I, Gevorgyan H, Luengo C, Pocard M, Payen D. Int Care Med. 2008;34(Supp 1):S257. Abstract 1008.
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).
Methods: 20 patients (nov 2006-dec 2007), ASA1 or 2, 9F/11 M, 53 y.o. (20–68), with peritoneal carcinomatosis. GA alone (n = 13) or associated to TEA (n = 7, T8-T9, ropivacaïne 2 mg/ml + sufentanyl 0. 5mcg/ml) settled before induction. Monitoring included: 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. Timing of measurements: viscerolysis, chemohyperthermia (HIPEC, oxaliplatin, 30 min, 42°C), end of the procedure. Statistics: non parametric tests.
Results: Procedure duration: 11 h (7–14) with a large fluid loading (15.5 ml/kg/h, range 7.1–28) with crystalloids (1/3 0.9% saline, 2/3 ringer lactate), comparable in both anaesthesia techniques. 3 patients required norepinephrine infusion. Hyperthermia: 1) under GA, BP, CO, ScvO2 or StO2 did not change;2) under GA + TEA, pre-hyperthermia CO tended to be higher than in GA (median TEA = 8.0 vs. GA = 6.6 L/min, p = 0.08); TEA modified the response to hyperthermia with PB decrease (p<0.05) without change in CO (intense vasodilatation) but with more reflex tachycardia (80 to 98 b/min, p<0.05). This sympathetic stimulation targeted the area unblocked by TEA (thenar eminence). The decrease of StO2 during arterial occlusion with TEA (median -0.30 to -0.45 %/sec, p<0.05) versus GA (-0.37 to -0.41 %/sec, NS) was faster (oxygen demand). The StO2 reperfusion slope (vascular reserve) did not differ between GA and TEA. In the TEA group, the more rapid was the drop of occlusion slope (rapid ischemia), the more rapid the reperfusion slope (vascular recruitment) (regression R = 0.67, Spearman test p = 0.04).
Conclusion: Before hyperthermia, TEA + GA induced hyperkinetic syndrome. Only in TEA + GA, hyperthermia induced a large vasodilatation that mainly concerns the unblocked area, as suggested by the remarkable rapid ischemia during arterial occlusion, which determined the vascular recruitment during reperfusion. The benefit of TEA associated with GA compared to GA alone remains to be demonstrated in postoperative period especially for inflammatory parameters.