5% dextrose peritoneal dialysis solution for 90 minutes. The coliseum technique was used. For gastrointestinal malignancies, mitomycin C (10-12.5 mg/m2) was

used. For mesothelioma and ovarian malignancies, cisplatin (50 mg/m2) and doxorubicin (15 mg/m2) or mitomycin C (10-12.5 mg/m2) were employed. Early postoperative intraperitoneal chemotherapy was postoperatively administered in accordance with previously defined guidelines (4). Anaesthesia At our institution, the indication for intraoperative RBC transfusion was a hemoglobin concentration <80 g/L and/or signs of anaemia (sinus tachycardia with a heart rate of >100 per minute, a systolic blood pressure Inhibitors,research,lifescience,medical of <100 mmHg, urine output of <30 mL/hr due to ongoing blood loss). To minimise unnecessary blood loss we have focused on maintaining normothermia and optimimizing acid-base balance. In the operating theatre, forced warm air blankets were applied and the head was covered

with a heat reflecting cap. All fluids and blood Inhibitors,research,lifescience,medical products were infused via fluid warming devices. Acidosis was managed by resuscitation and mechanical ventilation. Our response to fluid resuscitation and coagulopathy Inhibitors,research,lifescience,medical in patients expected to require an extensive procedure because of high volume disease has changed since June, 2006. Previously, we followed the standard resuscitation strategy with an emphasis on crystalloid and RBC administration to improve cardiac output and oxygen delivery. Procoagulant factors (FFP,

cryoprecipitate, platelets) were transfused in response to abnormal coagulation laboratory parameters, hypotension unresponsive to crystalloid administration, transfusion >6 units or obvious Inhibitors,research,lifescience,medical microvascular bleeding. Since June 2006, a protocol driven approach has been adopted which involves the early and aggressive administration of procoagulant factors Inhibitors,research,lifescience,medical (particularly FFP) to prevent rather than treat coagulopathy. In particular it was deemed not necessary to wait for laboratory results before initiating administration of procoagulants. Procoagulant factors were organized to be available from the outset of surgery and were given such that the ratio of FFP:RBC administered exceeded much 1:1, even through the early intraoperative period. Moreover, a fluid restriction strategy was pursued to minimize dilutional coagulopathy. The Mdm2 inhibitor rationale behind this change in strategy was multifactorial. Firstly, recent data from trauma surgery has shown that current resuscitation strategies severely underestimate the degree of coagulopathy during surgery. Secondly, our own experience showed that waiting for laboratory results before administering procoagulant factors often resulted in marked coagulation defects and significant blood loss, which could be reduced with a pre-emptive strategy.