Anesthetic management and renal function in pediatric patients undergoing cytoreductive surgery with continuous hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin

Our plain-English summary of Anesthetic management and renal function in pediatric patients undergoing cytoreductive surgery with continuous hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin, by P. Owusu-Agyemang, R. Arunkumar, H. Green, et al (Annals of Surgical Oncology, 2012).

The study

• Authors: P. Owusu-Agyemang, R. Arunkumar, H. Green, D. Hurst, K. Landoski, A. Hayes-Jordan
• Journal: Annals of Surgical Oncology
• Published: 2012;19(8):2652-6
• Cited by: 28 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Extensive tumor implants secondary to sarcoma, sarcomatosis, or mesothelioma in children is rare. We conducted the first phase 1 trial of escalating doses of cisplatin during hyperthermic intraperitoneal chemotherapy (HIPEC) in children with sarcomatosis. The most devastating complication of cisplatin therapy is nephrotoxicity. Here we present the anesthetic management and analysis of the impact of intraoperative fluid management on the incidence of renal failure.

Methods: Of the 10 patients under 18 years of age who underwent HIPEC in the context of our phase 1 trial, six patients were under the age of 10 years. We reviewed the anesthetic management, intraoperative fluid and blood administration, and postoperative renal function in these patients.

Results: The average age and weight were 6 years and 20.9 kg, respectively. To avoid renal toxicity, urine output was maintained at an average of 3 ml/kg/h. Crystalloid and colloid were transfused at an average rate of 9 ml/kg/h. Percentage increase in creatinine postoperatively varied from 33 to 500 %. Volume of fluid administered did not correlate with percentage increase in creatinine. All patients had a temporary increase in their serum creatinine, but none required dialysis.

Conclusions: Fluid administration at an average rate of 9 ml/kg/h was required to maintain satisfactory urine output. This rate of intraoperative fluid administration is similar to what is provided to adult HIPEC patients. There was no significant correlation in the volume or type of fluid delivered and the increase in serum creatinine. More studies are needed to determine optimal fluid management in children undergoing HIPEC with cisplatin.

In plain English

This report came from a phase 1 trial at the University of Texas M. D. Anderson Cancer Center. Children with tumors spread through the abdomen had surgery to remove the tumors, followed by heated cisplatin chemotherapy circulated in the abdomen (HIPEC). Ten patients under 18 were enrolled between January 2005 and October 2009, and the authors reviewed the records of the six who were under 10. The article says the diagnoses included mesothelioma and desmoplastic small round cell tumor but does not say how many patients had each. It does not discuss asbestos. The review covered anesthesia, intravenous fluids and kidney function. Operations lasted 10 to 16 hours. Fluids were given at an average of 9 ml/kg per hour (range 6 to 15), and urine output averaged 3 ml/kg per hour. Every child's serum creatinine, used as the measure of cisplatin kidney toxicity, rose after surgery, by 33% to 500%. None needed dialysis. The amount of fluid did not correlate with the creatinine rise. The authors concluded that these children needed more fluid than is usual in other major abdominal surgery, and that a larger group of patients is needed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of records of the six children under 10 years old treated in a single-center, investigator-initiated phase 1 dose-escalation trial (case series)
• Who was studied: Six children under age 10 (ages 3 to 9; mean weight 20.9 kg), out of 10 patients under 18 enrolled January 2005 to October 2009 at M. D. Anderson Cancer Center, Houston, Texas. Diagnoses included mesothelioma and desmoplastic small round cell tumor; the number with each diagnosis is not given.
• Exposure: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy using escalating doses of cisplatin, together with intraoperative fluid and anesthetic management. Asbestos exposure was not studied.
• Main results:
  • In the six children, the combined average rate of crystalloid and colloid given was 9 ml/kg/h (range 6 to 15 ml/kg/h). Crystalloid averaged 106 ml/kg (range 67 to 174 ml/kg).
  • Urine output was kept at an average of 3 ml/kg/h.
  • All six children had a postoperative rise in serum creatinine, ranging from 33% to 500% (table mean 197%). None required dialysis.
  • The volume of fluid given did not correlate with the percentage rise in creatinine. For example, two patients given fluid at the same rate (8 ml/kg/h) had creatinine rises of 50% and 275%.
  • Five of the six children needed blood transfusions. Blood transfusion did not correlate with the percentage rise in creatinine.
  • The two patients whose central venous pressure was mostly below 10 cm H2O had both the highest and the lowest creatinine rises. The authors suggested central venous pressure may not be a significant factor.
  • Three of six children had temporary creatinine increases that returned to baseline within 2 to 3 weeks. One 4-year-old who had two HIPEC procedures had a persistently elevated creatinine.
  • Operations lasted 10 to 16 hours, and there were no deaths or complications during surgery.
• The authors' conclusion: The authors concluded that fluid requirements in these children were higher than those associated with other major abdominal surgeries. They found no other specific differences in anesthetic management and said more studies are needed to determine optimal fluid management.
• Limitations the authors state:
  • The authors state that a larger group of patients is needed to determine how intraoperative fluid management affects kidney problems in these children.
  • The authors note that no comparable adult data were found, because cisplatin is not standard in adult HIPEC.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Cisplatin, Sarcoma, Mesothelioma, Nephrotoxicity.

Related studies

• Toxicity of hyperthermic intraperitoneal chemotherapy (HIPEC) in pediatric patients with sarcomatosis/carcinomatosis: early experience and phase 1 results — A. Hayes-Jordan, H. Green, et al. (2012)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up — P. Malekzadeh, M. Good, et al. (2021)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Utility of Chemoresponse Assay in Patients Undergoing Cytoreductive Surgery Plus Hyperthermic Intraperitoneal Chemotherapy — S. Bhagwandin, S. Naffouje, et al. (2015)

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