GA3-79
Anesthetic Management in a Pediatric Patient Undergoing Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Desmoplastic Small Round Cell Tumor: A Case Report
Tunceroglu H, Gilbertson L
Emory University, Atlanta, GA, USA
Introduction: Desmoplastic small round cell tumors (DSRCT) are an aggressive sarcoma affecting young males (1). Hyperthermic intraperitoneal chemotherapy (HIPEC) has been used in the treatment of adults with carcinomatosis, and involves the application of heated chemotherapeutic agents directly to the abdominal cavity. HIPEC procedures are complex with adult operative morbidity being 40% (2). HIPEC has now become a treatment option in children with sarcomatosis. To date, there are only 3 case reports in the literature regarding anesthetic management in pediatric HIPEC procedures.
Case Report: A 17-year-old male with DSRCT unresponsive to chemotherapy was scheduled to undergo tumor debulking and HIPEC. In the operating room, an epidural was placed followed by induction of anesthesia, intubation, central line placement, and arterial access. Prior to the HIPEC infusion, the room was cooled to 18 ËšC and ice packs were placed on the patient. Additionally, a cooling blanket was set to 0ËšC and a forced air blanket was placed on ambient. Cisplatin at 42ËšC was infused for 90 minutes. During the infusion, we were able to keep his maximum core temperature at 37.7 ËšC. In order to maintain urine output at 2cc/kg/hr, 5L of normal saline and 1L of albumin were administered during the procedure. The patient developed a metabolic acidosis (pH of 7.21) as well as mild coagulopathy. He was subsequently transported to the PICU intubated, and extubation occurred day 2 after normalizing his acid base status. He developed a mild increase in his creatinine which resolved by day 3.
Discussion: As HIPEC gains increased interest, there are many considerations to be addressed by the pediatric anesthesiologist. Complications include consumptive coagulopathy, nephrotoxicity, peripheral neuropathies, seizures, and arrhythmias. Hyperthermia is the key derangement, with the acceptable mean core temperature established as 39.2ËšC at many institutions (3). The induced hyperdynamic state leads to an increase in heart rate, cardiac index, and oxygen consumption. The fall in peripheral vascular resistance requires an increase in cardiac output that may necessitate the use of inotropes or vasopressors. There is a high risk of renal dysfunction (1-10%) and renal protection depends principally on attention to volume status. While there are reports of some institutions utilizing dopamine or diuretics, there is little evidence to suggest this improves outcomes. Moving forward, long term prospective studies are required to determine the efficacy of this treatment modality as well as the optimal anesthetic management in the pediatric population.
References:
1)Lae ME, et a.. Desmoplastic Small Round Cell Tumor: a Clinicopathologic, Immunohistochemical, and Molecular Study of 32 Tumors. Am J Surg Pathol. 2002 Jul;26(7):823-35.
2)Hays-Jordan A, et al. Toxicity of Hyperthermic Intraperitoneal Chemotherapy in Pediatric Patients with Sarcomatosis/Carcinomatosis. J. Pediatric Blood Cancer. 2012 Mar;59:395-397.
3)Weatherall A, et al. Staged Intraperitoneal Brachytherapy and Hyperthermic Intraperitoneal Chemotherapy in an Adolescent: Novel Anesthetic Challenges for Pediatric Anesthetics. J. Pediatric Anesthesia. 2017 Apr;27(4):338-345.
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