(PM P27) Anesthesia and Pain Management of Pediatric Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Desmoplastic Small Round Cell Tumors Utilizing a Tunneled Thoracic Epidural; Initiation of a New Pediatric HIPEC Program

Background. Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive soft tissue sarcoma characterized by extensive peritoneal metastases. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has shown to improve survival in patients with peritoneal dissemination of DSRCT. Here we present on the anesthetic management and postoperative pain control strategies using a multimodal opioid-sparing non-volatile anesthetic technique with tunneled thoracic epidural as we embark on the first Pediatric HIPEC program in the state of North Carolina. Methods. A retrospective review of pediatric patients undergoing CRS-HIPEC for DSRCT between July 2018 and August 2019 was conducted. All patients received premedication with gabapentin followed by intraoperative infusions of propofol, dexmedetomidine and ketamine. A tunneled thoracic epidural catheter was placed for management of pain. Results. We reviewed and analyzed the first 7 DSRCT CRS-HIPEC patient records. Median age of patients was 14 years (range 12-17). Six of the seven were male. Median operative duration was 739 minutes (range 560-1016) and median anesthesia duration was 821 minutes (range 638-1080). All patients were extubated in the OR and none required reintubation. Median intraoperative crystalloid fluid administration was 10.6 ml/kg/h (range 4.8-13.6) and colloid administration was 20.1 ml/kg (range 10.1-52.6). Median blood loss was 6.8 ml/kg (range 2.2-8.8). Four patients received intraoperative blood transfusion. Median intraoperative urine output was 3.4ml/kg/h (range 2.1-6.8). No patients received intraoperative diuretics and there were no incidences of acute kidney injury. Epidural infusions were used for a median of 8 days (range 6-13). Postoperative intravenous opioid use (morphine equivalent) was 0.0035mg/kg/day (range 0- 0.69) administered for a median of 1 day (range 0-10). Three of the seven patients received no IV narcotics in the postoperative time period. Conclusions. Utilizing a multimodal opioid-sparing non-volatile anesthetic technique in conjunction with a tunneled thoracic epidural catheter, we were able to avoid need for postoperative mechanical ventilation and minimize postoperative IV narcotic requirements.