Malign asitli over kanserinde sitoredüktif cerrahide perioperatif hemodinamik optimizasyon

Year 2022, Volume: 47 Issue: 3, 950 - 960, 30.09.2022

Güneş Özlem Yıldız , Gokhan Sertcakacilar , Duygu Akyol , Sema Karakaş , Gülsüm Oya Hergünsel

https://doi.org/10.17826/cumj.1097476

Abstract

Amaç: Bu çalışmada malign asitli epitelyal over kanserli hastalarda plazma onkotik basıncı ve intravasküler volümü korumak, perioperatif hemodinamik stabilizasyon ve doku perfüzyonunu sağlamak amacıyla norepinefrin ve albümin kullanımının etkilerini değerlendirmeyi amaçladık. Ayrıca postoperatif yoğun bakıma yatış, hastanede kalış ve komplikasyonlar açısından da karşılaştırılması amaçlandı.
Gereç ve Yöntem: Bu çalışmaya over kanseri nedeniyle sitoredüktif cerrahi uygulanan 38 asitli ve 28 asitsiz toplam 66 hasta dahil edildi. Hastaların hemodinamik stabilizasyon sonrası (ameliyat başladıktan sonra) (T0) PVI ve invaziv arter monitorizasyonu yapıldı. T0, 1. saat (T1) ve 2. saat (T2) ve postoperatif (Tpostop.) hastaların kan gazı ve hemodinamik verileri kaydedildi. Asit hastaları, norepinefrin (NE) infüzyonu, norepinefrin + albümin (NEA) infüzyonu veya sadece sıvı tedavisi (FT) uygulanan 3 alt gruba ayrıldı. Hastaların perioperatif hemodinamik ve laboratuvar verilerinden doku perfüzyonu laktat ile, hemodinamik durumu plet değişkenlik indeksi (PVI), perfüzyon indeksi (PI) ve ortalama arter basıncı (MAP) ile değerlendirildi.
Bulgular: Demografik ve klinik bulgular asitli ve asitsiz hastalar arasında anlamlı farklılık göstermedi. Tpostop'ta NEA/NE grubunda laktat düzeyi, T1h, T2h ve Tpostop zaman dilimlerinde PVI düzeyi FT grubuna göre daha yüksek saptandı. PI'nin T2 zaman çerçevesinde önemli ölçüde düşük olduğu bulundu. Ameliyat sonrası yoğun bakıma yatış oranı NEA ve NE gruplarında daha yüksekti. Grup NEA'da yoğun bakımda kalış süresi grup NE'ye göre daha kısaydı.
Sonuç: Malign asitli over kanseri cerrahisinde perioperatif hemodinamik optimizasyon, doku perfüzyonu ve plazma onkotik basıncı sağlamak için albümin ile düşük doz NE kullanımını öneriyoruz. Bu hastalarda yüksek sıvı replasmanına rağmen norepinefrin ve albüminin birlikte kullanılması perioperatif dönemde majör komplikasyonları önlemede/azaltmada önemli rol oynayabilir.

Keywords

epitelyal ovaryan kanser, hemodinamik monitörizasyon, sıvı yönetimi, malign asit

Optimization of perioperative hemodynamics in cytoreductive surgery of ovarian cancer with malignant ascites

Abstract

Purpose: In this study, we aimed to evaluate the effects of norepinephrine and albumin use in patients with epithelial ovarian cancer with malignant ascite in order to maintain plasma oncotic pressure and intravascular volume, to provide perioperative hemodynamic stabilization and tissue perfusion. In addition, it was aimed to compare in terms of postoperative intensive care admission, hospital stay and complications.
Materials and Methods: A total of 66 patients, 38 with ascites and 28 without ascites, who underwent cytoreductive surgery for ovarian cancer were included in this study. PVI and invasive arterial monitoring of the patients were performed after hemodynamic stabilization (after the start of surgery) (T0). T0, 1st hour (T1) and 2nd hour (T2) and postoperative (Tpostop.) Ascites patients were composed of 3 subgroups which the ones received norepinephrine (NE) infusion, norepinephrine + albumin (NEA) infusion or only fluid therapy (FT). From the perioperative hemodynamic and laboratory data of the patients, tissue perfusion was evaluated with lactate, and hemodynamic status was evaluated with pleth variability index (PVI), perfusion index (PI) and mean arterial pressure (MAP).
Results: Demographic and clinical findings did not differ significantly between patients with and without ascites. Lactate level in NEA / NE group in Tpostop, PVI level in T1h, T2h and Tpostop time frames were determined higher than the FT group. PI was found to be significantly lower in the T2 time frame. The postoperative ICU admission rate was higher in the NEA and NE groups. The duration of ICU stay in group NEA was shorter than in group NE.
Conclusion: We recommend the use of low-dose NE with albumin to provide perioperative hemodynamic optimization, tissue perfusion and plasma oncotic pressure in surgery of ovarian cancer with malignant ascites. Despite high fluid replacement in these patients, the use of norepinephrine and albumin together may have an important role in preventing / reducing major complications in the perioperative period.

Keywords

Epitelial ovarian cancer, fluid-therapy, hemodynamic monitoring, malignant ascites

References

• 1. Kobayashi E, Ueda Y, Matsuzaki S, Yokoyama T, Kimura T, Yoshino K, Fujita M, Kimura T, Enomoto T. Biomarkers for screening, diagnosis, and monitoring of ovarian cancer. Cancer Epidemiol Biomarkers Prev. 2012 Nov;21(11):1902-12. doi: 10.1158/1055-9965.EPI-12-0646.
• 2. Feldheiser A, Braicu EI, Bonomo T, Walther A, Kaufner L, Pietzner K, Spies C, Sehouli J, Fotopoulou C. Impact of ascites on the perioperative course of patients with advanced ovarian cancer undergoing extensive cytoreduction: results of a study on 119 patients. Int J Gynecol Cancer. 2014 Mar;24(3):478-87. doi: 10.1097/IGC.0000000000000069.
• 3. Hunsicker O, Fotopoulou C, Pietzner K, Koch M, Krannich A, Sehouli J, Spies C, Feldheiser A. Hemodynamic Consequences of Malignant Ascites in Epithelial Ovarian Cancer Surgery*: A Prospective Substudy of a Randomized Controlled Trial. Medicine (Baltimore). 2015 Dec;94(49):e2108. doi: 10.1097/MD.0000000000002108. 4. Ahmed S, Oropello JM. Critical care issues in oncological surgery patients. Crit Care Clin. 2010 Jan;26(1):93-106. doi: 10.1016/j.ccc.2009.10.004.
• 5.Schmidt C, Moritz S, Rath S, Grossmann E, Wiesenack C, Piso P, Graf BM, Bucher M. Perioperative management of patients with cytoreductive surgery for peritoneal carcinomatosis. J Surg Oncol. 2009 Sep 15;100(4):297-301. doi: 10.1002/jso.21322.
• 6. Herat LY, Schlaich MP, Matthews VB. Sympathetic stimulation with norepinephrine may come at a cost. Neural Regen Res. 2019 Jun;14(6):977-978. doi: 10.4103/1673-5374.250576.
• 7. Ngan Kee WD, Lee SW, Ng FF, Tan PE, Khaw KS. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology. 2015 Apr;122(4):736-45. doi: 10.1097/ALN.0000000000000601.
• 8. Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011 Mar;55(2):111-5. doi: 10.4103/0019-5049.79879.
• 9. Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Haas T, Jacob M, Lancé MD, Pitarch JVL, Mallett S, Meier J, Molnar ZL, Rahe-Meyer N, Samama CM, Stensballe J, Van der Linden PJF, Wikkelsø AJ, Wouters P, Wyffels P, Zacharowski K. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol. 2017 Jun;34(6):332-395. doi: 10.1097/EJA.0000000000000630.
• 10. Ba, M., Long, H., Zhang, X., Yan, Z., Wang, S., Wu, Y., ... & Cui, S. (2019). Ascites do not affect the rate of complete cytoreductive surgery and prognosis in patients with primary ovarian cancer with ascites treated with hyperthermic intraperitoneal chemotherapy. Oncology Letters, 18(2), 2025-2033.
• 11. Nagy JA, Masse EM, Herzberg KT, Meyers MS, Yeo KT, Yeo TK, Sioussat TM, Dvorak HF. Pathogenesis of ascites tumor growth: vascular permeability factor, vascular hyperpermeability, and ascites fluid accumulation. Cancer Res. 1995 Jan 15;55(2):360-8.
• 12. Cerne, Katarina, and Borut Kobal. "Ascites in Advanced Ovarian Cancer." Ovarian Cancer: From Pathogenesis to Treatment (2018): 197.
• 13. Nicholson JP, Wolmarans MR, Park GR. The role of albumin in critical illness. Br J Anaesth. 2000 Oct;85(4):599-610. doi: 10.1093/bja/85.4.599.
• 14. Akça O. Managing intraoperative blood pressure with norepinephrine: effects on perfusion and oxygenation of the intestinal tract. Anesthesiology. 2011 Mar;114(3):488-9. doi: 10.1097/ALN.0b013e31820bfb04.
• 15. Straat M, Müller MC, Meijers JC, Arbous MS, Spoelstra-de Man AM, Beurskens CJ, Vroom MB, Juffermans NP. Effect of transfusion of fresh frozen plasma on parameters of endothelial condition and inflammatory status in non-bleeding critically ill patients: a prospective substudy of a randomized trial. Crit Care. 2015 Apr 15;19(1):163. doi: 10.1186/s13054-015-0828-6.
• 16. Monnet X, Jabot J, Maizel J, Richard C, Teboul JL. Norepinephrine increases cardiac preload and reduces preload dependency assessed by passive leg raising in septic shock patients. Crit Care Med. 2011 Apr;39(4):689-94. doi: 10.1097/CCM.0b013e318206d2a3.
• 17. Renner J, Meybohm P, Hanss R, Gruenewald M, Scholz J, Bein B. Effects of norepinephrine on dynamic variables of fluid responsiveness during hemorrhage and after resuscitation in a pediatric porcine model. Paediatr Anaesth. 2009 Jul;19(7):688-94. doi: 10.1111/j.1460-9592.2009.03017.x.
• 18. Morelli A, Donati A, Ertmer C, Rehberg S, Kampmeier T, Orecchioni A, D'Egidio A, Cecchini V, Landoni G, Pietropaoli P, Westphal M, Venditti M, Mebazaa A, Singer M. Microvascular effects of heart rate control with esmolol in patients with septic shock: a pilot study. Crit Care Med. 2013 Sep;41(9):2162-8. doi: 10.1097/CCM.0b013e31828a678d.
• 19. Arslan, Mahmut, et al. "Can perfusion index or pleth variability index predict spinal anesthesia-induced hypotension during caesarean section?." Anestezi Dergisi 27.4 (2019): 251-257.
• 20. Jansen TC, van Bommel J, Bakker J. Blood lactate monitoring in critically ill patients: a systematic health technology assessment. Crit Care Med. 2009 Oct;37(10):2827-39. doi: 10.1097/CCM.0b013e3181a98899.
• 21. Zhong S, Zhong X, Zhong X, Liu Y. Comparison between the effect of epidural anesthesia combined with epidural analgesia and general anesthesia combined with intravenous analgesia on prognosis of ovarian cancer patients. Oncol Lett. 2019 Jun;17(6):5662-5668. doi: 10.3892/ol.2019.10216.
• 22. Amir M, Shabot MM, Karlan BY. Surgical intensive care unit care after ovarian cancer surgery: an analysis of indications. Am J Obstet Gynecol. 1997 Jun;176(6):1389-93. doi: 10.1016/s0002-9378(97)70366-1.
• 23. Puls LE, Duniho T, Hunter JE, Kryscio R, Blackhurst D, Gallion H. The prognostic implication of ascites in advanced-stage ovarian cancer. Gynecol Oncol. 1996 Apr;61(1):109-12. doi: 10.1006/gyno.1996.0106.
• 24. Kosary CL. FIGO stage, histology, histologic grade, age and race as prognostic factors in determining survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulva, and vagina. Semin Surg Oncol. 1994 Jan-Feb;10(1):31-46. doi: 10.1002/ssu.2980100107.