Page 47 - textbook5chapters
P. 47
Technique of Intraperitoneal Chemotherapy: Normothermic and Hyperthermic 1299
Figure 5. Severe adhesions around peritoneal catheter found at protected by a sterile drape. The port is stabilized with
the time of second-look surgery. the non-dominant hand and then accessed using a 19-22
gauge Huber needle (regular 1.5” and for obese patients
for improvement in patient’ condition then IV-only 2”). The needle is advanced until the back of the port is
chemotherapy can be given for initial course(s) (Table 2). reached and then withdrawn fractionally. Initially, 20cc
of normal saline is injected to be sure the port is patent
Appropriate preparation of patient and family and then a 250ml bag of normal saline is connected and
includes explanation of the procedure and the possible opened fully. If the saline is seen to flow rapidly under
immediate effects, including abdominal discomfort, gravity into the PC without any sign of leak the flow is
reduced appetite and difficulty breathing and delayed shut off. All solutions should be warmed to 37°C. A bag
toxicities. Delivery of the chemotherapy agents is best containing the chemotherapy agent mixed in one liter of
performed by nurses trained in the technique who should fluid is connected and allowed to run in rapidly by gravity
provide one-on-one nursing care, monitoring signs, for up to one hour. During the infusion the nurse stays
patient symptoms and needle placement at frequent with the patient to be sure that there is no obvious sign
intervals. Successful completion of IP treatment is greatly of leakage around the port. If a bedpan is used the nurse
improved by good communication with, and emotional must assure that proper needle position is maintained.
support from, the nursing staff (18).
The empty bag is replaced by one liter of normal
The patient empties her bladder and then lies saline which is again allowed to run in over up to one
supine but not completely flat since this may increase hour. Once the two liters of fluids are instilled, the Huber
pressure on the diaphragm and encourage respiratory needle is removed and a pressure dressing is applied. If
compromise or discomfort as abdominal distension the patient is unable to tolerate the full 2 liters of fluid
increases. Appropriate premedication and hydration are the rate of infusion can be slowed or the second bag
given. The skin is prepped widely around the port and infusion can be discontinued if necessary. During the
infusion period the patient is asked to lie still in a supine
position avoiding flexing at the waist which may reduce
the intraperitoneal volume and movement, which could
dislodge the needle during infusion (16). The patient is
now asked to move every 15 minutes for 2 hours using
the following positions, left side, right side, head up and
head down. During the 15 minutes assigned to head up
the patient may be allowed to go to pass urine and walk
about.
Following the completion of treatment the patient is
discharged home with regular chemotherapy precautions.
Some modifications of the GOG-172 chemotherapy
regimen are detailed in Table 4.
Table 4. Modified Regimens for Combination Intravenous/Intraperitoneal Chemotherapy
Author Site Year Day 1 Day 2 Day 8
IV IP IP IP
Armstrong (4) InP (D1,2) 2006 paclitaxel 135* (24h) cisplatin 100 paclitaxel 60
Lesnock(13) OutP 2010 paclitaxel 135 (3h) cisplatin 75 paclitaxel 40
Seamon OutP 2009 docetaxel 60-70 cisplatin 80-85 paclitaxel 60-70
Berry OutP 2009 docetaxel 75 cisplatin 75-100 paclitaxel 60
Gray InP 2010 paclitaxel 135 (24h) cisplatin 100
InP paclitaxel 135 (24h) carbo AUC 5-6
*mg/m2
InP = inpatient, OutP=outpatient, h = hours, AUC=area under the curve
IV=intravenous, IP=intraperitoneal
Additional references: Berry et al. Gynecol Oncol 2009;113:63-67, Seamon et al. Int J Gynecol Cancer 2009;19:1195-1198, Gray et al. Gynecol
Oncol 2010;116:340-344.
