An isolated limb infusion technique: a guide for the perfusionist.
ABSTRACT Isolated limb perfusion with the administration of cytotoxic drugs has been successfully used to treat melanomas of the extremity since it was first introduced in 1958. The use of hyperthermia (40 degrees C) combined with chemotherapy agents, primarily melphalan, has resulted in greater cytotoxicity in laboratory studies, which led to the application of hyperthermia in clinical studies during the 1960s. The effectiveness of this regional technique and the absence of any good systemic therapy made hyperthermic-isolated limb perfusion (HILP) the main treatment for patients with regionally advanced melanoma. HILP involves open surgical dissection and cannulation of the peripheral vessels and is associated with moderate morbidity rates. Blood transfusions, systemic drug leak, infection, and damage to the blood vessels and nerves are all potential hazards associated with this technique. Recently, however, there has been increased interest in an alternative technique termed isolated limb infusion (ILI), which was first reported in 1994 from the Sydney Melanoma Unit in Australia. Based on a few single institution experiences, it was found that there are fewer morbidities associated with HILP than with ILI but no compromise in patient outcomes. ILI is a less invasive procedure involving the use of angiographically placed catheters inserted percutaneously through the femoral vessels that does not require blood donor exposure or use of a heart lung machine. Preliminary data suggest that the resultant local hypoxia and acidosis induced by this procedure potentiates the cytotoxic effects of melphalan. Response rates comparing ILI to HILP seem similar, and both are markedly better than systemic chemotherapy. ILI may be a more desirable option because morbidity is greatly reduced and outcomes appear similar. There is a potential role for the perfusionist in the application of ILI, an evolving area of cancer therapy.
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ABSTRACT: Blood cardioplegia delivery systems are employed in most pediatric open heart cases to arrest the heart and keep it preserved during aortic cross-clamping. They are also used as part of a modified ultrafiltration system at the end of cardiopulmonary bypass. We evaluated and compared the air-handling capabilities of different types of blood cardioplegia delivery devices. A simple circuit incorporating a cardiotomy reservoir, a roller pump, a cardioplegia test system, and two emboli detection and classification sensors were used to investigate the air-handling capabilities of the following cardioplegia delivery systems: GISH Vision, Maquet Plegiox, Medtronic Trillium MYOtherm XP, Sorin Group BCD Vanguard, Sorin Group CSC14, and Terumo Sarns Conducer and Bubble Trap. The 0.25-in. circuit was primed with 400mL of Lactated Ringer's. Outdated packed red blood cells were added to obtain a hematocrit of 24-28%. System pressure was maintained at 50mmHg. Air (0.1, 0.3, 0.5mL) was injected at a speed of 0.1mL/s into the circuit just after the pump head. Gaseous microemboli (GME) were measured prior to the cardioplegia system and after the device to evaluate the air-handling characteristics. The tests were run at 100, 200, and 400mL/min blood flow for both 4 and 37°C. There were no significant differences among the groups when comparing precardioplegia delivery system GME, thus demonstrating that all devices received the same amount of injected air. When comparing the groups for postcardioplegia delivery system GME, significant differences were noted especially at the 400mL/min blood flow rate. These results suggest that for the devices compared in this study, the Maquet Plegiox and the Medtronic Trillium MYOtherm XP eliminated GME the best.Artificial Organs 11/2010; 34(11):950-4. · 1.96 Impact Factor
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ABSTRACT: Two forms of regional chemotherapy for the treatment of advanced melanoma or sarcoma of the extremity are isolated limb perfusion (ILP) and the more recently described isolated limb infusion (ILI). Melphalan is the most commonly employed agent in both ILP and ILI, although it is often used in conjunction with other cytotoxic and/or biologic therapies. While ILP and ILI are far more effective for the treatment of extremity disease than is systemic therapy, there is still significant room for improvement in outcomes, from the standpoint of both response rate and toxicity. An understanding of the pharmacokinetics of regional chemotherapy would allow for the prediction of tumor response and toxicity and therefore patient outcomes. In addition, elucidating the mechanisms of drug resistance would lead to opportunities to develop effective chemo-modulators that enhance the effectiveness of ILP and ILI. This paper reviews progress in these two key areas of active investigation.International Journal of Hyperthermia 06/2008; 24(3):239-49. · 2.59 Impact Factor
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ABSTRACT: Hyperthermic isolated limb perfusion (HILP) is used for patients with intractable or extensive in-transit metastatic melanoma of the limb to deliver high concentrations of cytotoxic agents to the affected limb and offers a treatment option in a disease stage with a poor prognosis when no treatment is given. In a retrospective chart review of 17 cases, we studied the anesthetic and hemodynamic changes during HILP and its management. HILP was well tolerated except in one case that is described herein. We present summary data of all cases undergoing upper and lower limb perfusion, discuss our current clinical practice of preoperative, perioperative and intraoperative patient care including the management of HILP circuit. HILP is a challenging procedure, and requires a team effort including the surgical team, anesthesia care providers, perfusionists and nurses. Intraoperatively, invasive hemodynamic and metabolic monitoring is indispensable to manage significant hemodynamic and metabolic changes due to fluid shifts and release of cytokines.BMC Anesthesiology 07/2013; 13(1):15. · 1.19 Impact Factor
Dale Scott Lawson