Effect of standardized fluid management on cardiac function after CRS + HIPEC in patients with PMP: a single-center case-control study

Abstract

Objective

To investigate the effects of standardized fluid management (SFM) on cardiac function in patients with pseudomyxoma peritonei (PMP) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Method

Patients with PMP who underwent CRS + HIPEC at our center were retrospectively analyzed. The patients were divided into control and study groups according to whether SFM was applied after CRS + HIPEC. We compared the preoperative and postoperative cardiac and renal function parameters, daily fluid volume three days after CRS, and cardiovascular-related adverse events. Univariate and multivariate analyses were performed to identify the indicators affecting clinical prognosis.

Result

Among the 104 patients, 42 (40.4%) were in the control group and 62 (59.6%) in the study group. There were no statistically significant differences between the two groups in the main clinicopathological characteristics, preoperative cardiac and renal function parameters, and CRS + HIPEC-related indicators. The incidences of cardiac troponin I (CTNI) > upper limit of normal (ULN), >2 × ULN, >3 × ULN, serum creatinine > ULN, and blood urea nitrogen > ULN were higher in the control group than in the study group (p < 0.05). The median daily fluid volume of the control group was higher than that of the study group 3 days after CRS (p < 0.05). Postoperative CTNI > 2 × ULN was an independent risk factor for serious circulatory adverse events. Survival analysis revealed pathological grading, completeness of cytoreduction score, and postoperative CTNI > ULN as independent prognostic factors.

Conclusions

SFM after CRS + HIPEC in patients with PMP may reduce cardiovascular adverse events risk and improve clinical outcomes.

Keywords:

• Pseudomyxoma peritonei
• cytoreductive surgery
• hyperthermic intraperitoneal chemotherapy
• standardized liquid management
• cardiac function

Introduction

Pseudomyxoma peritonei (PMP) is a malignant clinical syndrome characterized by the accumulation and redistribution of mucus produced by mucinous tumor cells in the peritoneal cavity with clinical manifestations of mucinous ascites, peritoneal implantation, omental cake, and ovarian involvement [1]. The incidence of PMP is approximately 2–4 cases in 1 million per year [1–4], and the prevalence is approximately 25.1 cases in 1 million [5], making it a rare disease.

Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard treatment for PMP [6,7]. CRS + HIPEC can improve patient survival by maximizing the resection of tumors and eliminating residual tumor cells in the abdominal cavity, resulting in improved overall survival of up to 103.4–196 months and 5-year and 10-year survival rates up to 92.1% and 80.8%, respectively [8–12].

As a complex surgery, CRS + HIPEC involves multiple visceral organs and parietal peritoneum resection, more bleeding and exudation, and more postoperative abdominal drainage, increasing the risk of fluid balance disorder and cardiovascular adverse events. Therefore, perioperative fluid management is vital in these patients.

This study aimed to explore the correlation between standardized fluid management (SFM) and N-terminal pro-hormone brain natriuretic peptide (NT-proBNP), myocardial injury markers (cardiac troponin I, CTNI; creatine kinase MB, CK-MB), and cardiovascular adverse events in patients with PMP after CRS + HIPEC and analyze its impact on clinical prognosis. The primary endpoint of this study was the level of postoperative myocardial injury markers in patients with PMP, and the secondary endpoint was the survival rate.

Patients and methods

Clinical information

This study was approved by the institutional review board of Beijing Shijitan Hospital, Capital Medical University (2015-[28]). All patients signed an informed consent to receive CRS + HIPEC and for the use of their clinicopathological data for further research and academic publications.

This retrospective case-control study included 104 patients with PMP treated with CRS + HIPEC at Beijing Shijitan Hospital from July 2015 to March 2022. Data regarding the basic clinicopathological characteristics, CRS + HIPEC-related information, preoperative and postoperative cardiac and renal function-related indicators (NT-proBNP; CTNI; CK-MB; serum creatinine, SCr; blood urea nitrogen, BUN), and daily fluid volume for 3 days after CRS were collected. A total of 104 PMP patients were divided into a control group (operation before 31 December 2018) and a study group (operation after 1 January 2019) since the application of the standardized postoperative fluid management tool began at our center in January 2019.

Patient selection

All patients met the criteria for CRS + HIPEC surgery [13], and the inclusion criteria were as follows: (1) Karnofsky performance status score > 60; (2) normal peripheral blood white blood cell count ≥ 3,500/mm³ and platelet count ≥ 80,000/mm³; (3) acceptable liver function, with total bilirubin ≤ 2× the upper limit of normal (ULN) and aspartic aminotransferase and alanine aminotransferase ≤ 2 × ULN; (4) acceptable renal function, with serum creatinine ≤1.5 mg/dL; and (5) other major organ functions can tolerate a major operation. Major exclusion criteria include (1) preoperative examination revealing distant metastases; (2) imaging examination indicating mesenteric contracture; and (3) the performance status and function of vital organs that cannot tolerate major surgery.

CRS + HIPEC procedure

A peritoneal metastasis specialist team at our center performed all CRS + HIPEC procedures. After successful general anesthesia, a midline incision was made in the upper abdomen from the xiphoid process to the pubic symphysis to expose the abdominal cavity fully, and the peritoneal cancer index (PCI) score was comprehensively evaluated. After CRS, the completeness of cytoreduction (CC) was evaluated based on the residual tumor size. Open HIPEC was performed with [cisplatin 120 mg + docetaxel 120 mg] or [cisplatin 120 mg + mitomycin 30 mg] at 43 °C for 60 min. Subsequently, a functional reconstruction and abdominal closure were performed.

Standardized postoperative fluid management tools

The principle of SFM after CRS + HIPEC is to ensure effective circulating blood volume, avoid aggravating cardiopulmonary burden, and achieve ‘accurate volume control, fine speed adjustment, and real-time monitoring’. Therefore, we developed a postoperative total parenteral nutrition (TPN) configuration tool, an input and output recording tool, and a fluid load monitoring tool to accomplish individualized fluid therapy, real-time fluid input and output monitoring, and dynamic fluid equilibrium management.

TPN configuration tool (Figure 1): The daily total postoperative fluid was divided into therapeutic and nutritional fluids, with a total volume of 35–45 ml/(kg × d), which was adjusted according to the amount of input and output. Therapeutic fluids include conventional antibiotics, anti-stress drugs, and essential organ protection drugs, which can be formulated individually according to the condition. Nutritional fluid intake was individually calculated according to the patient’s sex, age, weight, and nutritional status. Based on EXCEL and functional language, a TPN nutritional treatment plan configuration table was created to visually display the dosage and energy ratio of each component of glucose, amino acids, fat emulsion, electrolytes, vitamins, and trace elements. While meeting the total energy of 25–35 kcal/kg, the ratio of glycolipid energy supply should be approximately 6:4, the ratio of energy to nitrogen should be 100–220:1 kcal/g, and the insulin scheme was configured based on glucose to insulin ratio of 4–6:1 g/U to maintain blood glucose balance.

Figure 1. Total parenteral nutrition (TPN) configuration tool.

Output and input statistical tool (Figure 2): A statistical tool was developed to record the volume of postoperative recovery at different stages based on EXCEL, leading to a liquid balance analysis unit of time accurately to an hour from the day. In real-time, the nurse filled in the amount of input (volume of intravenous fluids and diet) and output (volume of drainage, urine, and stool), from which doctors understood the fluid balance status in real-time and adjusted the treatment plan accordingly.

Figure 2. Statistical tool for assessing postoperative input and output.

Each patient was digitally monitored for fluid load using NT-ProBNP and central venous pressure (CVP). NT-ProBNP can sensitively reflect the degree of cardiac preload according to its detection value, particularly the trend of values to adjust the fluid therapy strategy in a timely manner. CVP can reflect cardiac function status and venous return of cardiac blood, as a simple monitoring index to control the velocity and volume of fluid therapy.

Study endpoints

The primary endpoint of this study was the level of postoperative CTNI, CK-MB in patients with PMP. The secondary endpoint was the survival rate.

Definition

Adverse events (AEs) were defined as complications occurring within 30 days of CRS + HIPEC. According to Sugarbaker’s textbook on peritoneal metastasis [14–15], AEs are graded into five levels of severity: Grade I, asymptomatic and self-limited; Grade II, symptomatic and requiring medical treatment; Grade III, requiring invasive intervention; Grade IV, requiring ICU admission or reoperation; and Grade V, postoperative death. Serious adverse events (SAEs) included grade III-V AEs.

Overall survival (OS) was defined as the time interval from the date of clinical diagnosis to the date of death or last follow-up.

Statistical analysis

Microsoft Excel 2016 and IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA) was used for data analysis. Measurement data are presented as median (range) or mean ± SD and analyzed by t-test or rank-sum test. Enumeration data were presented as frequencies and analyzed using the χ2 and Fisher’s exact tests. Univariate and logistic regression analyses were used to analyze the independent factors influencing postoperative AEs. The Kaplan–Meier method and log-rank test were used for survival analysis. Univariate and multivariate analyses were used to analyze the independent prognostic factors affecting survival. Statistical significance was set at p < 0.05.

Result

Major clinicopathological characteristics

A total of 104 patients with PMP were included; of these, 62 (59.6%) were males and 42 (40.4%) were females. The median patient age was 57 (range, 31–76). Patients were divided into a control group (42 cases, 40.4%) and a study group (62 cases, 59.6%) according to whether they received SFM after surgery. There were no statistically significant differences in sex, age, chemotherapy history, KPS score, preoperative cardiac and renal function parameters, or other clinicopathological characteristics between the two groups (p > 0.05) (Table 1).

Table 1. Major clinicopathological characteristics, preoperative cardiac and renal function parameters of PMP patients in this study.

Variables	Control group (n = 42)	Study group (n = 62)	p value
Gender, n (%)			0.695
Male	26 (61.9)	36 (58.1)
Female	16 (38.1)	26 (41.9)
Age (years), median (range)	57 (33–76)	56 (31–76)	0.666
Intravenous chemotherapy, n (%)			0.206
No	32 (76.2)	40 (64.5)
Yes	10 (23.8)	22 (35.5)
KPS, median (range)	90 (70–100)	90 (60–100)	0.067
Pathological diagnosis, n (%)			0.997
Low grade	21 (50.0)	31 (50.0)
High grade	14 (33.3)	21 (33.9)
High grade with signet ring cells	7 (16.7)	10 (16.1)
Vascular invasion, n (%)			0.628
No	41 (97.6)	58 (93.5)
Yes	1 (2.4)	4 (6.5)
Lymphatic metastasis, n (%)			1.000
No	38 (90.5)	55 (88.7)
Yes	4 (9.5)	7 (11.3)
Preoperative NT-proBNP > ULN, n (%)			0.715
NO	39 (92.9)	55 (88.7)
Yes	3 (7.1)	7 (11.3)
Preoperative CK-MB > ULN, n (%)			NA
No	42 (100.0)	62 (100.0)
Yes	0 (0.0)	0 (0.0)
Preoperative CTNI > ULN, n (%)			NA
No	42 (100.0)	62 (100.0)
Yes	0 (0.0)	0 (0.0)
Preoperative SCr > ULN, n (%)			NA
No	42 (100.0)	62 (100.0)
Yes	0 (0.0)	0 (0.0)
Preoperative BUN > ULN, n (%)			0.314
No	40 (95.2)	62 (100.0)
Yes	2 (4.8)	0 (0.0)

KPS: Karnofsky performance status score; ULN: upper limit of normal; SCr: serum creatinine; BUN: blood urea nitrogen; NA: not applicable.

CRS + HIPEC characteristics

There were no statistically significant differences in the main operation-related indicators between the two groups, including operation duration, number of organ resection, blood loss, red blood cell transfusion volume, plasma transfusion volume, ascites volume, PCI, CC0-1 resection ratio, and number of anastomosis (p > 0.05) (Table 2).

Table 2. Major CRS + HIPEC characteristics of PMP patients between control and study groups.

Variables	Control group (n = 42)	Study group (n = 62)	p value
Operative duration (min), mean ± SD	598.9 ± 186.16	627.1 ± 136.74	0.378
Resected organs, median (range)	4 (0–8)	4 (0–9)	0.134
Anastomosis, n (%)			0.796
No	9 (21.4)	12 (19.4)
Yes	33 (78.6)	50 (80.6)
PCI, median (range)	29.5 (3.0–39.0)	30.0 (1.0–39.0)	0.774
CC, n (%)			0.517
0–1	21 (50.0)	35 (56.5)
2–3	21 (50.0)	27 (43.5)
Blood loss volume (mL), median (range)	600 (100–5,000)	600 (50–2,400)	0.619
Fluid transfusion volume (mL), mean ± SD	7,564.8 ± 2,643.00	7,176.0 ± 2,679.85	0.469
Urine volume (mL), median (range)	1,650 (600–4,500)	1,800 (600–8,000)	0.503
RBC transfusion volume (U), median (range)	2 (0–20)	4 (0–10)	0.288
Plasma transfusion volume (mL), median (range)	800 (0–1,500)	800 (0–1,200)	0.216
Ascites volume (mL), median (range)	800 (0–20,000)	600 (0–10,000)	0.398

PCI: peritoneal cancer index; CC: completeness of cytoreduction; RBC: red blood cells.

Postoperative Fluid volume

The median fluid volume on postoperative days (POD) 1, 2, and 3 in the control vs. study groups were 48.8 (range, 37.1–86.8) vs. 44.7 (range, 33.5–76.0) mL/(kg × d) on POD1 (p = 0.002), 50.9 (range, 34.4–93.2) vs. 43.4 (range, 31.1–64.9) mL/(kg × d) on POD2 (p < 0.001), and 47.7 (range, 30.9–78.8) vs. 41.6 (range, 31.1–60.7) mL/(kg × d) on POD3 (p < 0.001), respectively (Figure 3). The median daily fluid volume of the control group was higher than that of the study group 3 days after CRS (p < 0.05) and was greater than 45 ml/(kg × d).

Figure 3. Comparison of fluid volumes in control vs. study groups by postoperative day (POD). (A) Comparison in median fluid volume on POD1 (**p = 0.002); (B) Comparison in median fluid volume on POD2 (***p < 0.001); (C) Comparison in median fluid volume on POD3 (***p < 0.001).

Postoperative Cardiac and renal Function parameters

Among the 104 patients, there were 34 cases with postoperative CTNI > ULN, including 20 cases (20/42, 47.6%) in the control group and 14 cases (14/62, 22.6%) in the study group (p = 0.008); 23 patients with CTNI > 2 × ULN, including 14 cases (14/42, 33.3%) in the control group and 9 cases (9/62, 14.5%) in the study group (p = 0.023); 18 patients with CTNI > 3 × ULN, including 12 cases (12/42, 28.6%) in the control group and 6 cases (6/62, 9.7%) in the study group (p = 0.012); 15 patients with SCr > ULN, including 11 cases (11/42, 26.2%) in the control group and 4 cases (4/62, 6.5%) in the study group (p = 0.005); 61 patients with BUN > ULN, including 33 cases (33/42, 78.6%) in the control group and 28 cases (28/62, 45.2%) in the study group (p = 0.001). The duration of CTNI > ULN, SCr > ULN and BUN > ULN respectively were 1.7 ± 2.6 vs. 0.9 ± 2.3 days (p = 0.009), 0.7 ± 1.8 vs. 0.2 ± 1.1 days (p = 0.005) and 3.6 ± 3.0 vs. 2.0 ± 3.0 days (p = 0.001) for the control vs. study groups (Table 3). There was no statistically significant difference in the incidence and duration of NT-proBNP or creatine kinase MB (CK-MB) > ULN between the two groups (p > 0.05).

Table 3. The degree and duration of postoperative elevation in cardiac and renal function parameters between control and study groups.

Variables	Control group (n = 42)	Study group (n = 62)	p value
NT-proBNP > ULN, n (%)			0.840
No	4 (9.5)	4 (6.5)
Yes	38 (90.5)	58 (93.5)
Duration of NT-proBNP > ULN, mean ± SD (day)	3.4 ± 2.90	4.3 ± 3.09	0.053
CTNI > ULN, n (%)			0.008
NO	22 (52.4)	48 (77.4)
Yes	20 (47.6)	14 (22.6)
CTNI > 2 × ULN, n (%)			0.023
No	28 (66.7)	53 (85.5)
Yes	14 (33.3)	9 (14.5)
CTNI > 3 × ULN, n (%)			0.012
No	30 (71.4)	56 (90.3)
Yes	12 (28.6)	6 (9.7)
Duration of CTNI > ULN, mean ± SD (day)	1.7 ± 2.59	0.9 ± 2.25	0.009
CK-MB > ULN, n (%)			0.285
No	22 (52.4)	39 (58.7)
Yes	20 (47.6)	23 (41.3)
Duration of CK-MB > ULN, mean ± SD (day)	0.9 ± 1.32	0.4 ± 0.56	0.088
SCr > ULN, n (%)			0.005
No	31 (73.8)	58 (93.5)
Yes	11 (26.2)	4 (6.5)
Duration of SCr > ULN, mean ± SD (day)	0.7 ± 1.81	0.2 ± 1.08	0.005
BUN > ULN, n (%)			0.001
No	9 (21.4)	34 (54.8)
Yes	33 (78.6)	28 (45.2)
Duration of BUN > ULN, mean ± SD (day)	3.6 ± 3.01	2.0 ± 3.01	0.001

ULN: upper limit of normal; NT-proBNP: N-terminal pro-hormone brain natriuretic peptide; CTNI: cardiac troponin I; CK-MB: creatine kinase MB; SCr: serum creatinine; BUN: blood urea nitrogen.

SAEs

Among the 104 patients with PMP, 34 (32.6%) had postoperative SAEs, including 21 (20.2%) cases involving the respiratory system, 12 (11.5%) cases involving infection, 9 (8.7%) cases involving the hematological system, 7 (6.7%) cases involving the digestive system, 6 (5.8%) cases involving the circulatory system, 6 (5.8%) cases involving the urinary system, and 1 (1.0%) case involving the nervous system. No deaths occurred within 30 days of surgery. There was no statistically significant difference in the incidence of SAEs between the two groups (Table 4).

Table 4. SAEs between control and study groups.

Variable	Control group (n = 42)	Study group (n = 62)	p value
Total SAEs, n (%)			0.112
No	32 (76.2)	38 (61.3)
Yes	10 (23.8)	24 (38.7)
Cardiovascular SAEs, n (%)			0.356
No	38 (90.5)	60 (96.8)
Yes	4 (9.5)	2 (3.2)

SAEs: serious adverse events.

Correlation analysis showed that the following 3 factors were associated with cardiovascular SAEs: postoperative NT-proBNP > 3 × ULN (p = 0.028), CTNI > ULN (p = 0.002), and CTNI > 2 × ULN (p = 0.028) (Table 5).

Table 5. Correlation analysis of postoperative NT-proBNP and myocardial injury markers with cardiovascular SAEs after CRS + HIPEC in PMP patients.

Variables	No cardiovascular SAEs (n = 98)	Cardiovascular SAEs (n = 6)	p value
NT-proBNP > ULN, n (%)			1.000
No	8 (8.2)	0 (0)
Yes	90 (91.8)	6 (100.0)
NT-proBNP > 3 × ULN, n (%)			0.028
No	54 (55.1)	0 (0)
Yes	44 (44.9)	6 (100.0)
CTNI > ULN, n (%)			0.002
No	70 (71.4)	0 (0)
Yes	28 (28.6)	6 (100.0)
CTNI > 2 × ULN, n (%)			0.028
No	79 (80.6)	2 (33.3)
Yes	19 (19.4)	4 (66.7)
CTNI > 3 × ULN, n (%)			0.104
No	83 (84.7)	3 (50.0)
Yes	15 (15.3)	3 (50.0)
CK-MB > ULN, n (%)			0.085
No	60 (61.2)	1 (16.7)
Yes	38 (38.8)	5 (83.3)
CK-MB > 2 × ULN, n (%)			0.127
No	82 (83.7)	3 (50.0)
Yes	16 (16.3)	3 (50.0)

ULN: upper limit of normal; NT-proBNP: N-terminal pro-hormone brain natriuretic peptide; CTNI: cardiac troponin I; CK-MB: creatine kinase MB; SAEs: serious adverse events.

The above factors were incorporated into the binary logistic regression model for multivariate analysis, which showed that postoperative CTNI > 2 × ULN was an independent factor for cardiovascular SAEs (p = 0.019, OR = 8.316, 95% confidence interval (CI) 1.417–48.807). The risk of cardiovascular SAEs in patients with a CTNI > 2 × ULN was 8.316 times higher than that in patients with normal CTNI.

Survival analysis

As of October 1, 2022, among 104 patients with PMP, the median follow-up was 41.4 months (95%CI: 36.7–46.1). There were 73 (70.2%) patients who were alive, and 31 (29.8%) died, with a mean OS of 74.7 months (95%CI: 63.3–86.1) (Figure 4). There was a statistically significant difference in the mOS between the control and study groups (65.3 vs. 73.6 months, p = 0.040).

Figure 4. Survival analysis. (A) Overall survival analysis of all patients; (B) Survival curve analysis of control group and study group.

Univariate survival analysis

Univariate analysis showed that the following factors affected the prognosis of PMP patients: KPS score (p = 0.013), pathological grading (p = 0.012) (Figure 5(A)), vascular invasion (p = 0.015), lymphatic metastasis (p = 0.008), CC score (p < 0.001) (Figure 5(B)), ascites volume (p = 0.008), postoperative NT-proBNP > 3 × ULN (p = 0.017), NT-proBNP > 5 × ULN (p = 0.009), CTNI > ULN (p = 0.001) (Figure 5(C)), CTNI > 2 × ULN (p = 0.001), and CTNI > 3 × ULN (p = 0.010).

Figure 5. Univariate analysis of survival. (A) Pathological grading; (B) CC score; (C) CTNI > ULN.

Multivariate survival analysis

Factors with p < 0.05 in univariate survival analysis were incorporated into the Cox regression model for multivariate analysis, which identified the following three independent prognostic factors: pathological grading, CC score, and postoperative CTNI > ULN (Table 6). Patients with postoperative CTNI > ULN had a 4.005 times higher risk of death than those with normal postoperative CTNI (p = 0.001, OR = 3.999, 95%CI 1.805–8.856).

Table 6. Multivariate survival analysis of PMP patients after CRS + HIPEC.

Variables	Wald	OR	95%CI	p
CC
2–3 vs. 0–1	6.439	3.287	1.311–8.242	0.011
Pathological grading
High grade with signet ring cells vs. Low grade	7.584	4.004	1.492–10.747	0.006
Postoperative CTNI > ULN
Yes vs. No	11.671	3.999	1.805–8.856	0.001

OR: odds ratio; CI: confidence interval; CC: completeness of cytoreduction; ULN: upper limit of normal; CTNI: cardiac troponin I.

Discussion

This study showed that SFM significantly impacted cardiac function after CRS + HIPEC in PMP patients. The incidence and degree of increased CTNI were higher in the control group than in the study group. Univariate and multivariate analyses showed that postoperative CTNI > 2 × ULN was an independent risk factor for cardiovascular SAEs, while pathological grading, CC score, and postoperative CTNI > ULN were independent prognostic factors for survival.

CRS + HIPEC treatment is complex and involves multiple resections of the visceral organs and parietal peritoneum [16], leading to more bleeding and exudation. Therefore, the patients are prone to a liquid balance disorder. Postoperative fluid management is critical, because excessive rehydration may lead to high blood chlorine, fluid overload, renal vascular stenosis, and increase the risk of intestinal anastomotic fistula [17–18], in contrast, too little rehydration may cause low blood volume with insufficient perfusion of the microcirculation, leading to organ dysfunction and other SAEs [19–21].

Regarding postoperative fluid management, goal-directed fluid therapy (GDFT) has attracted considerable attention. GDFT involves the principle of volume responsiveness to individualized fluid therapy under hemodynamic monitoring. In a randomized controlled study by Pearse et al. [22] on 122 high-risk general surgery patients, 62 cases in the study group received postoperative GDFT, while 60 patients in the control group received traditional fluid rehydration. This study showed that GDFT could reduce postoperative complications and hospital stays. A meta-analysis by Chao et al. [23] showed that GDFT could not improve the postoperative prognosis of colorectal surgery patients compared to traditional fluid therapy. Currently, GDFT remains a topic of debate, with different reports on its clinical benefits. No unified conclusion has been reached regarding fluid selection, monitoring index selection, or the use of vasoactive drugs.

Clinically, doctors usually dynamically adjust infusion volume by monitoring various postoperative outputs, NT-ProBNP, CVP and other clinical indicators of patients, thereby avoiding too much or too little rehydration. However, in clinical practice, there are significant differences in the experience of postoperative fluid management among clinicians, and it is challenging to standardize and individualize postoperative fluid management. Such variations inevitably affect clinical outcomes. To minimize such differences, we designed a standardized postoperative fluid management tool to optimize postoperative fluid management and realize real-time, dynamic, individualized SFM, which can reduce postoperative cardiovascular SAEs. This study showed that a postoperative CTNI > 2 × ULN was an independent risk factor for postoperative cardiovascular SAEs, and a CTNI > ULN was an independent prognostic factor. SFM can significantly reduce the probability and degree of CTNI abnormalities and the risk of postoperative cardiovascular SAEs. Gorgun et al. [24] showed that the postoperative CTNI level in patients undergoing gastrointestinal surgery was associated with 30-day to 1-year postoperative mortality. Other studies have shown [25–28] that preoperative calponin levels in patients undergoing non-cardiac surgery have a predictive value for postoperative cardiovascular SAEs. Both preoperative and postoperative troponin levels are important risk predictors of postoperative SAEs, and treatment strategies should be promptly adjusted in response to troponin levels.

A meta-analysis by Rodseth et al. [29] showed that the postoperative NT-proBNP level in patients who underwent non-cardiac surgery was associated with postoperative mortality and heart failure within 30, 180 days after surgery. Fisher et al. [30] found that NT-proBNP measurement in patients after CRS + HIPEC can guide postoperative fluid management and help identify patients with a significant risk of cardiopulmonary SAEs. However, multivariate analysis showed that NT-proBNP level > 3 × ULN was not an independent risk factor for cardiovascular SAEs.

This study has some limitations. First, because the detection methods of NT-proBNP and CTNI in our center were updated during the study, the comparison and analysis in this study were not the original values of brain natriuretic peptide (BNP) and CTNI. However, the multiples of their original values and ULN, and the data conversion may affect the sensitivity of the statistical analysis. Second, this was a single-center retrospective case-control study with a moderate sample size, and higher-level studies must verify the conclusions.

In conclusion, SFM after CRS + HIPEC in patients with PMP may reduce the risk of cardiovascular SAEs and improve clinical outcomes.

Disclosure statement

The authors report there are no competing interests to declare.

Additional information

Funding

This work was supported by the [General Program of National Natural Science Foundation of China] under Grant [number 82073376].