HEMOdynamic Proactive Management During Cytoreductive Surgery and Intraperitoneal hyPErthermic Chemotherapy for Advanced Ovarian Cancer

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex surgical procedure carried out through laparotomic approach. Intraoperative management represents a challenge for anesthesiologist: hemodynamic instability (due to extremely destructive surgery with fluids shift and blood loss), biochemical abnormalities (worsened by cytotoxic chemotherapic agents peritoneal infusion, with profound metabolic acidosis and electrolytes disturbance), and extreme thermal fluctuations related to the different phases of surgery.

CRS-HIPEC is fraught with significant drawbacks: morbidity and mortality rates go up to 20%-40% and 3% respectively, and acute kidney injury and pulmonary effusion/oedema are the most frequent postoperative complications. More than 70% of the patients are admitted in Intensive Care Unit after the surgery.

Intraoperative hypotension (IOH) during CRS-HIPEC is common, and as it is associated with the potential for harm [9]. At the same time, extensive fluid resuscitation in peritoneal cancer patients is associated with a poor postoperative outcome, and avoiding fluid overload is recommended. Optimizing flow and pressure requires repeated measurement of both variables and use of established protocols for vasopressor and fluid administration (the so called "individualized hemodynamic management") has been shown to be associated with decreased postoperative complications compared to routine care. Efficient and accurate control of arterial pressure and cardiac output is a major concern during CRS-HIPEC, because it requires frequent manual adjustments of vasopressor infusion rates and timely fluid administration.

A peculiar aspect of CRS-HIPEC is the delicate phase of intraoperative chemotherapy. During this procedure, hyperthermia and the extensive cytolysis caused by the chemotherapeutic drug lead to multifactorial metabolic acidosis and intense vasodilation: managing fluid therapy and vasoconstrictor drugs is often extremely challenging.

The aim of this study is to perform a pilot study describing a hemodynamic management protocol based on artificial intelligence - derived parameters, that allows to implement the standard goal directed therapy (GDT) protocol in term of amount of IOH and stroke volume (SV) optimization during CRS-HIPEC.