Cuidados de enfermería para citorreducción y quimioterapia intraoperatoria hipertérmica en la Unidad de Cuidados Intensivos: revisión del alcance

Branco, Aline; Weston, Fernanda Cirne Lima; Soares, Giovanna da Rosa; Linch, Graciele Fernanda da Costa; Caregnato, Rita Catalina Aquino

doi:10.1590/1980-220X-REEUSP-2024-0176en

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Review • Rev. esc. enferm. USP 58 • 2024 • https://doi.org/10.1590/1980-220X-REEUSP-2024-0176en linkcopiar

Cuidados de enfermería para citorreducción y quimioterapia intraoperatoria hipertérmica en la Unidad de Cuidados Intensivos: revisión del alcance

Autoría SCIMAGO INSTITUTIONS RANKINGS

Objetivo: Mapear los cuidados de enfermería postoperatorios para pacientes adultos y ancianos críticamente enfermos ingresados en la Unidad de Cuidados Intensivos después de una cirugía citorreductora con quimioterapia intraperitoneal hipertérmica.

Método: Revisión del alcance según metodología JBI, con artículos extraídos de bases de datos y literatura gris, sin delimitación de idioma ni fecha de publicación. El proceso de selección de estudios y extracción de resultados fue realizado por dos revisores independientes, a través de los programas EndNote^® y Rayyan^®. Se utilizó PRISMA. Extension for Scoping Reviews para la redacción, registrándose en el Open Science Framework.

Resultados: Se seleccionaron 42 estudios. El análisis mostró 72 tipos de atención agrupados en 14 áreas de atención. El uso de un catéter epidural para analgesia, la optimización del estado hemodinámico individualizado y el control estricto del balance hídrico fueron las medidas citadas con mayor frecuencia.

Conclusión: El mapeo identificó cuidados de enfermería postoperatorios similares a los de cirugía mayor para pacientes recuperados en la Unidad de Cuidados Intensivos, con indicaciones para el uso de equipos de protección personal para los profesionales en la manipulación de drenajes en las primeras 48 horas de ingreso.

DESCRITORES
Quimioterapia Intraperitoneal Hipertérmica; Unidades de Cuidados Intensivos; Cuidados Posoperatorios; Recuperación Mejorada Después de la Cirugía; Atención de Enfermería

Database	Search strategy	Results
PubMed (MEDLINE)	(Cytoreduction Surgical Procedures[mh] OR Cytoreduct[tiab] OR Debulk[tiab]) AND (Hyperthermic Intraperitoneal Chemotherapy[mh] OR Hyperthermia, Induced[mh:noexp] OR Hyperthermic Intraperitoneal Chemotherap[tiab] OR HIPEC[tiab] OR Hot Chemotherap[tiab] OR Intraperitoneal Hyperthermic Chemotherap[tiab] OR Induced Hypertherm[tiab] OR Therapeutic Hypertherm[tiab] OR Thermotherap[tiab] OR Fever Therap[tiab] OR Local Hypertherm[tiab]) AND (Intensive Care Units[mh:noexp] OR Respiratory Care Units[mh] OR Critical Care[mh] OR Critical Care Nursing[mh] OR Intensive care[tiab] OR Critical care[tiab] OR ICU[tiab] OR Care Unit[tiab] OR Nursing Care[mh:noexp] OR Medical-Surgical Nursing[mh] OR Oncology Nursing[mh] OR Nurses[mh] OR Nursing[tiab] OR Nurse[tiab] OR Postoperative Period[mh] OR Postoperative Care[mh] OR Recovery Room[mh] OR Enhanced Recovery After Surgery[mh] OR Postoperat[ti] OR Post-operat[ti] OR Post-surg[ti] OR Recover[ti])	315
CINAHL	(MH “Cytoreduction Surgical Procedures” OR TI ( Cytoreduct* OR Debulk* ) OR AB ( Cytoreduct* OR Debulk* ) OR SU ( Cytoreduct* OR Debulk* ) AND (MH ( “Hyperthermic Intraperitoneal Chemotherapy” OR “Hyperthermia, Induced” ) OR TI ( “Hyperthermic Intraperitoneal Chemotherap” OR “HIPEC” OR “Hot Chemotherap” OR “Intraperitoneal Hyperthermic Chemotherap” OR “Induced Hypertherm” OR “Therapeutic Hypertherm” OR “Thermotherap” OR “Fever Therap” OR “Local Hypertherm” ) OR AB ( “Hyperthermic Intraperitoneal Chemotherap” OR “HIPEC” OR “Hot Chemotherap” OR “Intraperitoneal Hyperthermic Chemotherap” OR “Induced Hypertherm” OR “Therapeutic Hypertherm” OR “Thermotherap” OR “Fever Therap” OR “Local Hypertherm” ) OR SU ( “Hyperthermic Intraperitoneal Chemotherap” OR “HIPEC” OR “Hot Chemotherap” OR “Intraperitoneal Hyperthermic Chemotherap” OR “Induced Hypertherm” OR “Therapeutic Hypertherm” OR “Thermotherap” OR “Fever Therap” OR “Local Hypertherm” ) AND (MH ( “Intensive Care Units” OR “Respiratory Care Units” OR “Critical Care” OR “Critical Care Nursing” OR “Nursing Care” OR “Medical-Surgical Nursing” OR “Oncology Nursing” OR “Nurses” OR “Postoperative Period” OR “Postoperative Care” OR “Recovery Room” OR “Enhanced Recovery After Surgery” ) OR TI ( “Intensive care” OR “Critical care” OR “ICU” OR “Care Unit” OR “Nursing” OR “Nurse” OR “Postoperat” OR “Post-operat” OR Post-surg* OR Recover* ) OR AB ( “Intensive care” OR “Critical care” OR “ICU” OR “Care Unit” OR “Nursing” OR “Nurse” ) OR SU ( “Intensive care” OR “Critical care” OR “ICU” OR “Care Unit” OR “Nursing” OR “Nurse” )	57

Assistance areas	Mapped care	Presentation of studies
Hemodynamic Monitoring	Observe the need for fluid replacement, transfusion of blood products, electrolytes and initiation of inotropes or vasopressors according to the individualized hemodynamic assessment(¹,²,⁴,⁵,⁷,⁹,¹⁰,¹⁴,²⁶,²⁷,²⁸,²⁹,³⁰,³¹,³²,³³,³⁴,³⁵,³⁶).	Systematic review(⁴,⁹), cross-sectional study(¹⁰,²⁸,³¹,³⁵), narrative literature review(²,⁵,⁷,¹⁴,²⁶,²⁷,²⁹,³²,³⁴,³⁶), experience report(¹), book chapter(³⁰,³³).
	Strictly control fluid balance, monitoring fluid gains and losses through thoracic and abdominal drains, nasogastric/nasoenteric tubes, and urinary catheter/spontaneous diuresis(¹,²,⁴,⁵,⁷,¹³,²⁷,²⁹,³⁰,³²,³³,³⁴,³⁶,³⁷).	Systematic review(⁴), narrative literature review(²,⁵,⁷,¹³,²⁷,²⁹,³²,³⁴,³⁶,³⁷), experience report(¹), book chapter(³⁰,³³).
	Evaluate laboratory tests: observing electrolyte values, coagulation profile, hematocrit and hemoglobin, acid-base balance, lactate, and other relevant tests(²,⁴,⁵,¹³,¹⁴,²⁹,³⁰,³⁶,³⁷,³⁸).	Systematic review(⁴), cross-sectional study(³⁸), narrative literature review(²,⁵,¹³,¹⁴,²⁹,³⁰,³⁶,³⁷).
	Monitor for signs of bleeding and hemorrhage(³,⁵,⁷,²⁹,³⁰).	Narrative literature review(⁵,⁷,²⁹), case study(³), book chapter(³⁰).
	Monitor vital signs and hemodynamic patterns, based on assessment of invasive mean arterial pressure, central venous pressure, cardiac output and index, and heart rate, in addition to peripheral perfusion(¹,¹³,¹⁴,²⁹,³³,³⁷,³⁸).	Cross-sectional study(³⁸), experience report(¹), narrative literature review(¹³,¹⁴,²⁹,³⁷), book chapter(³³).
	Pay attention to kidney function, observing urinary volume and evaluating laboratory tests for urea and creatinine, observing signs of edema, measuring body weight and imaging tests(¹,⁵,⁷,⁹,¹³,²⁶,²⁸,³⁰,³²,³⁶).	Systematic review(⁹), cross-sectional study(²⁸), experience report(¹), narrative literature review(⁵,⁷,¹³,²⁶,³²,³⁶), book chapter(³⁰).
	Observe the need for monitoring intra-abdominal pressure, mainly for patients who had pressure above 12 cmH2O during surgery(³⁹).	Cross-sectional study(³⁹).
Mechanical Ventilation and Oxygen Therapy	Assess the need to keep the patient on invasive mechanical ventilation in the ICU, considering hemodynamic instability and complications related to the intraoperative and postoperative periods(²,⁴,¹³,¹⁴,²⁶,²⁹,³²,³⁷,³⁸).	Systematic review(⁴), cross-sectional study(³⁸), narrative literature review(²,¹³,¹⁴,²⁶,²⁹,³²,³⁷).
	Opt for early weaning and extubation as soon as possible in the operating room or ICU(¹,²,⁴,¹⁴,²⁸,²⁹,³¹,³²,³³).	Systematic review(⁴), cross-sectional study(²⁸,³¹), experience report(¹), narrative literature review(²,¹⁴,²⁹,³²), book chapter(³³).
	After extubation, opt for non-invasive ventilation such as continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC), with the multidisciplinary team(⁴,⁷,²⁵,²⁷,²⁹,³²,³³).	Systematic review(⁴), retrospective cohort study(²⁵), narrative literature review(⁷,²⁷,²⁹,³²), book chapter(³³).
	Perform bronchial hygiene by aspirating secretions from the airways and stimulating coughing, along with deep breathing exercises and spirometry(⁵,⁹,¹³,³³,⁴⁰).	Systematic review(⁹), cross-sectional study(⁴⁰), narrative literature review(⁵,¹³), book chapter(³³).
	Observe signs of ventilatory complications in the postoperative period(¹³,²⁶,³¹,³²,³⁷,³⁸).	Cross-sectional study(³¹,³⁸), narrative literature review(¹³,²⁶,³²,³⁷).
	Use a nasogastric tube for decompression and avoid the risk of aspiration(³⁷).	Narrative literature review(³⁷).
	Monitor respiratory pattern, with lung auscultation and documentation of sounds every 4 hours(¹,²,¹³,²⁸,³¹,³³,³⁶,³⁷,³⁸).	Cross-sectional study(²⁸,³¹,³⁸), experience report(¹), narrative literature review(²,¹³,³⁶,³⁷), book chapter(³³).
Neurological Pattern	Monitor the patient’s awakening process(⁴¹).	Cross-sectional observational study(⁴¹).
Patient Pain Assessment and Care	Use multimodal analgesia: combination of local anesthetics or opioids in the epidural catheter with nonsteroidal anti-inflammatory drugs or other analgesics(²,⁸,⁹,¹⁰,¹⁴,¹⁸,¹⁹,²⁰,²⁵,⁴⁰,⁴²).	Systematic review(⁸,⁹), cohort study(¹⁹,²⁵,⁴⁰,⁴²), cross-sectional study(¹⁰,²⁰), narrative literature review(²,¹⁴,¹⁸).
	Avoid the use of intravenous opioids by using other forms of analgesia such as an epidural catheter(⁸,⁹,¹⁰,²⁷,²⁸).	Systematic review(⁸,⁹), cross-sectional study(¹⁰,²⁸), narrative literature review(²⁷).
	Establish specialized services for acute pain, in the “Pain Service” modality. In cases of chronic pain, contact the Palliative Care team(²⁶,³²,⁴²).	Cohort study(⁴²), narrative literature review(²⁶,³²).
	Perform analgesia through an epidural catheter as a safe method for pain control(⁴,⁷,⁸,⁹,¹⁴,¹⁸,¹⁹,²⁰,²⁴,²⁵,²⁶,²⁷,²⁹,³¹,³²,³³,³⁴,³⁶,³⁸,⁴⁰,⁴¹,⁴²,⁴³).	Systematic review(⁴,⁸,⁹), cohort study(¹⁹,²⁵,⁴⁰,⁴²), cross-sectional study(²⁰,³¹,³⁸,⁴¹), narrative literature review(⁷,¹⁴,¹⁸,²⁴,²⁶,²⁷,²⁹,³²,³⁴,³⁶,⁴³), book chapter(³³).
	Keep the epidural catheter in use until the transition of analgesia to oral or IV and discontinuation of the catheter(⁴,⁸,¹³,¹⁹,²⁴,²⁵,²⁶,³⁶,⁴⁰,⁴²).	Systematic review(⁴,⁸), cohort study(¹⁹,²⁵,⁴⁰,⁴²), narrative literature review(¹³,²⁴,²⁶,³⁶).
	Maintain assessment and care for pain relief, documenting it every 4 hours using appropriate scales(³,¹³,³³).	Case study(³), narrative literature review(¹³), book chapter(³³).
	Manage pain through Patient Controlled Analgesia (PCA) or transversus abdominis plane block (TAP) by the anesthetist, associated with multimodal analgesia(¹⁰,¹³,¹⁴,¹⁸,²⁵,³³,³⁶,⁴²,⁴³).	Cohort study(²⁵,⁴²), cross-sectional study(¹⁰), narrative literature review(¹³,¹⁴,¹⁸,³⁶,⁴³).
	Use PCA only with the patient awake and instructed on its use(¹³,³³).	Narrative literature review(¹³), book chapter(³³).
	Keep the epidural catheter in use for pain relief for 72 to 96 hours, with some studies suggesting use up to the 5th and 8th day postoperatively(⁴,⁸,¹³,¹⁴,²⁴,²⁵,²⁶,³⁶).	Systematic review(⁴,⁸), cohort study(²⁵), narrative literature review(¹³,¹⁴,²⁴,²⁶,³⁶).
	Control analgesic infusion via epidural catheter according to hemodynamic and neurological patterns. Maintain an aseptic environment during handling and maintenance(⁸,²⁶,⁴²).	Systematic review(⁸), cohort study(⁴²), narrative literature review(²⁶).
Surgical Wound	Assess the surgical incision for signs of infection, keeping it protected with a sterile dressing, and observe for bleeding or the presence of fistulas(⁵,³³).	Narrative literature review(⁵), book chapter(³³).
	To prevent dehiscence, instruct the patient to cough using a pillow while pressing firmly on the incision(⁵,³³).	Narrative literature review(⁵), book chapter(³³).
	Assess negative pressure dressing for integrity and function(³⁶).	Narrative literature review(³⁶).
Care of Drains, Ostomies, Probes, Tubes and Catheters	Assess the volume and appearance of fluids drained through thoracic and abdominal drains and nasogastric or nasoenteric tubes(²,⁵,¹³,²⁶,³³,³⁷).	Narrative literature review(²,⁵,¹³,²⁶,³⁷), book chapter(³³).
	Observe the appearance of secretion from ostomies, surgical wound and rectum. Inform the medical team if there are signs of content change(¹³,³⁷).	Narrative literature review(¹³,³⁷).
	Use dry sterile gauze to protect the skin around the drains(³³,³⁶).	Narrative literature review(³⁶), book chapter(³³).
	Daily assess the need to maintain a nasogastric tube and drainage of residual content(¹⁰,²⁰).	Cross-sectional study(¹⁰,²⁰).
	Observe the volume of chest drains and the need for permanence. Reservoirs should never be more than half full, monitoring the volume every 1-2 hours(¹³,³³).	Narrative literature review(¹³), book chapter(³³).
	Beware that the installation of a nasogastric tube is not recommended for all patients, if there is no risk of delayed gastric emptying due to omentum resection(⁸,²⁸).	Systematic review(⁸), cross-sectional study(²⁸).
	Remove urinary catheter, nasogastric tube, thoracic and abdominal drains within 72 hours of hospitalization, or as soon as possible(¹⁰,¹⁹,²⁰,²⁸).	Cohort study(¹⁹), cross-sectional study(¹⁰,²⁰,²⁸).
	Introduce the patient and family to ostomy care(¹⁸).	Narrative literature review(¹⁸).
Rational Prevention and Management of Infections	Properly clean hands with soap and water, especially before and after contact with the patient’s drains, secretions and surgical sites(¹⁸,³³).	Narrative literature review(¹⁸), book chapter(³³).
	Involve family and patient in education about signs and symptoms of surgical site infection, and instruct on hand washing and use of personal protective equipment(¹⁸).	Narrative literature review(¹⁸).
	Maintain an aseptic environment for insertion of central catheters, using Doppler ultrasound to guide insertion, as well as adequate manipulation of the pathways and hand hygiene(²¹,³⁷).	Cohort study(²¹), narrative literature review(³⁷).
	Use antibiotics rationally and scale them according to the results of appropriate cultures and the patient’s condition(²,⁴,²⁹).	Systematic review(⁴), narrative literature review(²,²⁹).
	Pay attention to signs of infection due to changes in the composition of drainage in drains and the surgical wound(⁵,²³,³⁷).	Cohort study(²³), narrative literature review(⁵,³⁷).
Glycemic Control	Maintain strict glycemic control. The target glucose value in critically ill patients should be between 140 – 180 mg/dL(⁴,⁸,⁹,¹⁹,²⁶,²⁹).	Systematic review(⁴,⁸,⁹), cohort study(¹⁹), narrative literature review(²⁶,²⁹).
	Pay attention to hyperglycemia, commonly observed, requiring the use of insulin, especially in patients undergoing interventions on the pancreas(⁴,⁸,¹⁹,²⁶).	Systematic review(⁴,⁸), cohort study(¹⁹), narrative literature review(²⁶).
	Assess the need for continuous insulin infusion to correct hyperglycemia(⁹,²⁹).	Systematic review(⁹), narrative literature review(²⁹).
Thermal Control	Monitor temperature postoperatively, continuously and rigorously, using heated fluids and thermal blankets(¹⁰,¹⁴,³²).	Cross-sectional study(¹⁰), narrative literature review(¹⁴,³²).
Thermal Control	Maintain normothermia (body temperature > 36°C) and evaluate serum lactate along with other inflammatory markers to assess tissue perfusion(⁴,¹⁰,³⁰,³²).	Systematic review(⁴), cross-sectional study(¹⁰), narrative literature review(³²), book chapter(³⁰).
Nutritional Control	Give preference to oral nutrition. If there are abdominal complications in which the patient does not tolerate enteral nutrition, start parenterally if the nutritional delay exceeds more than three days(⁴,⁷,⁹,¹⁴,¹⁸,³⁶,³⁷,³⁸,⁴⁴,⁴⁵).	Systematic review(⁴,⁹), cohort study(⁴⁴), cross-sectional study(³⁸), narrative literature review(⁷,¹⁴,¹⁸,³⁶,³⁷,⁴⁵).
	Start nutrition as soon as possible, providing clear fluids on the first day after surgery. Progress according to acceptance, tolerance, and clinical evaluation to a low-residue diet, and then to solid foods(⁷,⁸,⁹,¹⁰,¹⁴,¹⁹,²⁰,²⁵,²⁸,²⁹,³²,³³,³⁸,⁴⁵).	Systematic review(⁸,⁹), cohort study(¹⁹,²⁵), cross-sectional study(¹⁰,²⁰,²⁸,³⁸), narrative literature review(⁷,¹⁴,²⁹,³²,⁴⁵), book chapter(³³).
	Assess bowel function by listening for bowel sounds, flatulence, evacuation and gastric residue volume, documenting acceptance and weight gain(⁸,⁹,¹³,²⁴,²⁸,³³,³⁶).	Systematic review(⁸,⁹), cross-sectional study(²⁸), narrative literature review(¹³,²⁴,³⁶), book chapter(³³).
	Observe the patient’s tolerance to the nutritional modality offered to identify those with insufficient nutrition and signs of complications(¹⁸,²⁴,³³).	Narrative literature review(¹⁸,²⁴), book chapter(³³).
	Associate intravenous fluid supply for energy supply, if necessary (⁴,⁷,¹³,¹⁴,²⁴,²⁸,³⁶,³⁷,³⁸).	Systematic review(⁴), cross-sectional study(²⁸,³⁸), narrative literature review(⁷,¹³,¹⁴,²⁴,³⁶,³⁷).
	Start total parenteral nutrition (TPN) as early as possible in case of signs of complications that prevent enteral route. The duration of TPN is based on nutritional status, complications, and caloric count(⁴,⁷,³⁰,36-38).	Systematic review(⁴), cross-sectional study(³⁸), narrative literature review(⁷,³⁶,³⁷), book chapter(³⁰).
	Avoid undue postoperative fasting for more than 24 hours, as this is a risk factor for prolonged ICU stay(⁷,³⁷,³⁸,⁴⁶).	Cohort study(⁴⁶), cross-sectional study(³⁸), narrative literature review(⁷,³⁷).
	Do not administer oral feeding (NPO), if at risk due to the surgical condition, until return of bowel sounds, flatulence and a decrease in gastric residues(¹³,³³).	Narrative literature review(¹³), book chapter(³³).
	Use prokinetics, laxatives and chewing gum to prevent paralytic ileus(⁸,¹⁹,²⁸).	Systematic review(⁸), cohort study(¹⁹), cross-sectional study(²⁸).
Mobilization	Encourage early mobilization from the first postoperative day(⁴,⁵,⁸,⁹,¹⁰,²⁰,²⁴,²⁸,⁴⁰).	Systematic review(⁴,⁸,⁹), cohort study(⁴⁰), cross-sectional study(¹⁰,²⁰,²⁸), narrative literature review(⁵,²⁴,⁴⁰).
	Change the position in bed every two hours, taking care with the thoracic and abdominal drains(¹³,³³).	Narrative literature review(¹³), book chapter(³³).
	Mobilize in bed on the first postoperative day and between the first and fourth postoperative day encourage getting out of bed to use an armchair and walk(7-10,¹⁹,²⁴,²⁵,³³,⁴⁰).	Systematic review(⁸,⁹), cohort study(¹⁹,²⁵,⁴⁰), cross-sectional study(¹⁰), narrative literature review(⁷,²⁴), book chapter(³³).
	Monitor drainage and drain preservation, surgical incision, and hemodynamic changes during mobilization(³⁸,⁴¹).	Cross-sectional study(³⁸,⁴¹).
Stress Ulcer and DVT Prophylaxis	Prevent stress ulcers by using H2 receptor antagonists and proton pump inhibitors, as prescribed by the doctor(²,²⁹,³¹).	Cross-sectional study(³¹), narrative literature review(²,²⁹).
	Administer, as prescribed by the physician, pharmacological prophylaxis with low molecular weight heparin or unfractionated heparin, and use intermittent lower limb compressors and graduated compression stockings(²,⁴,⁵,⁷,⁸,⁹,¹⁴,¹⁹,²⁹,³³).	Systematic review(⁴,⁸,⁹), cohort study(¹⁹), narrative literature review(²,⁵,⁷,¹⁴,²⁹), book chapter(³³).
	Start pharmacological prophylaxis 12 hours before surgery, extending until the fourth week of hospitalization or until complete mobilization(⁴,⁸,⁹,¹⁹).	Systematic review(⁴,⁸,⁹), cohort study(¹⁹).
	Promote adequate hydration, early ambulation, leg exercises while in bed or chair(³³).	Book chapter(³³).
Mental Health and Family Care	Adjust nursing staffing to better care for this patient profile(¹).	Experience report(¹).
	Maintain direct, clear and effective communication with the patient and family, involving information about the surgical procedure, recovery process, expected symptoms and adverse effects, treatment plans and joint decision-making about therapy(¹⁸,²²,²⁴,⁴⁷,⁴⁸).	Qualitative study(²²,⁴⁷,⁴⁸), narrative literature review^(18.24).
	Involve patient and family in educating them about the care that will be needed post-operatively and during the recovery process(⁹,¹⁸,²²,²⁴).	Systematic review(⁹), qualitative study(²²), narrative literature review(¹⁸,²⁴).
	Promote embracing, support for needs, humanized care, encourage the patient to face cancer and strengthen the bond of trust among the patient, family, and multidisciplinary team(³²,⁴⁷,⁴⁸).	Qualitative study(⁴⁷,⁴⁸), narrative literature review(³²).
	Consider the need for psychological support and social assistance. Whenever possible, conduct a visit to the ICU before the procedure as part of guidance and to reduce post-operative anxiety(²⁴,²⁵,³²).	Cohort study(²⁵), narrative literature review(²⁴,³²).
	Promote quality sleep, reduce noise in the ICU, and allow open visits by family members(²⁴,⁴⁷).	Qualitative study(⁴⁷), narrative literature review(²⁴).
Occupational Care for Staff	Keep the lid down when flushing to dispose of waste. Clothes contaminated with secretions must be bagged and sent to the laundry to be washed separately from the rest(²,¹³).	Narrative literature review(²,¹³).
	Appropriate attire during handling and disposal of drain fluids and urine for up to 48 hours post-operatively. Use a waterproof apron, cap, procedure gloves, protective glasses and surgical mask(¹,³,⁵,¹³).	Experience report(¹), case study(³), narrative literature review(⁵,¹³).
	Prevent pregnant women or those who intend to become pregnant, people with a history of cancer or immunocompromised individuals from providing assistance to patients undergoing HIPEC, or in the 48 hours postoperatively(⁵,⁷).	Narrative literature review(⁵,⁷).

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[1] Note: Pubmed - National Library of Medicine; CINAHL - Cumulative Index to Nursing and Allied Health Literature.