The metabolic effect of 7,5% icodextrin vs 0,9% NaCl as carrier solutions for chemotherapy drugs in HIPEC procedures

Abstract

Objectives: Glucose-containing solutions are commonly used as carrier fluids during hyperthermic intraperitoneal chemotherapy (HIPEC) but concerns regarding hyperglycaemia and possible associated infection risks have led to the use of isotonic crystalloids as an efficient alternative. However, to date the metabolic implications of these alternatives remain largely unexplored. This study compares the metabolic effects of different HIPEC carrier solutions, namely a carbohydrate dialysate: 7,5% icodextrin and 0,9% NaCl solution. Methods: We conducted a single-centre, retrospective, propensity-matched cohort study including 34 patients undergoing cytoreductive surgery (CRS) with HIPEC, in which the carrier solution for the chemotherapy drugs was either 0.9% NaCl (n = 17) or 7.5% icodextrin (n = 17). Blood analyses were performed after induction of anaesthesia, immediately postoperatively upon ICU admission and on postoperative day one. Intraoperative fluid and electrolyte substitution and postoperative insulin administration were recorded. Clinical outcomes included the duration of invasive ventilation and postoperative hemodynamic support. Results: Glycaemic levels were slightly higher in the icodextrin group but this was not statistically significant. Insulin administration was significantly higher in this cohort. Both groups developed metabolic acidosis which resolved on post op day one. In the icodextrin group this was attributed to significant hyperlactatemia. The 0,9% NaCl group showed a hyperchloremic metabolic acidosis, confirmed by a low strong ion difference on Stewart analysis and characterized by significantly reduced plasma bicarbonate and CO2 levels. Potassium chloride supplementation was significantly higher in the icodextrin group, sodium bicarbonate and potassium phosphate use were comparable. No differences in vasopressor and ventilatory support were observed. Conclusions: HIPEC carrier solutions exert significant and distinct perioperative metabolic effects. Glucose-containing solutions, namely 7.5% icodextrin, induce hyperlactatemic acidosis requiring increased insulin and concomitant potassium supplementation. 0,9% NaCl induced a more profound and longer hyperchloremic metabolic acidosis likely due to peritoneal chloride absorption. Further research should consider systemic perioperative metabolic derangements and their potential impact on postoperative outcomes when selecting the optimal HIPEC carrier solution during CRS.