Percutaneous hepatic perfusion in patients with metastatic liver cancer: anesthetic, hemodynamic, and metabolic considerations.

Abstract

Percutaneous hepatic perfusion (PHP), a regional cancer therapy, entails insertion of percutaneous catheters to isolate hepatic vasculature and enable simultaneous hepatic venous hemofiltration of high-dose chemotherapy. PHP has been shown to be safe and to benefit some patients with liver metastases. We examined hemodynamic and metabolic changes as well as anesthetic implications during PHP in patients with metastatic liver cancer enrolled in clinical trials of escalating doses of melphalan between 2001 and 2006. Fifty-one patients underwent 136 PHPs with general anesthesia. Diagnoses included neuroendocrine tumors, melanoma, and metastatic carcinomas. Based upon available data derived from all procedures, incorporating multiple procedures per patient, after occlusion of the inferior vena cava and during hepatic perfusion, there were decreases in mean arterial (-15.4 +/- 1 and -7.4 +/- 1 mmHg, respectively) and central venous pressure (-5.4 +/- 0.3 and -5.6 +/- 0.3 mmHg) and increases in heart rate (11 +/- 1 and 13.4 +/- 0.9 bpm) (all p < 0.0001) which resolved with completion of the procedure. During vascular isolation, patients received norepinephrine (13% of procedures), phenylephrine (70%), or both agents (11%). During hepatic perfusion with melphalan, compared to baseline, there were decreases in pH (-0.09 +/- 0.01) and bicarbonate (-3.3 +/- 0.6 mmol/L) (both p < 0.0001) and, upon completion of procedure, increases (2.6 +/- 0.4 mmol/L) in bicarbonate, compared to values during hepatic perfusion (p < 0.0001). PHP therapy can be associated with transient but significant hemodynamic and metabolic perturbations. In order to assure patient comfort and facilitate timely diagnosis and treatment of associated hemodynamic and metabolic changes, we favor administration of general anesthesia, rather than sedation, for patients undergoing PHP.