Aseptic Thermochemical Shock after Hyperthermic Intrathoracic Chemotherapy: Pathophysiological Mechanisms and a Translational Framework for Perioperative Management

Hyperthermic intrathoracic chemotherapy has emerged as a promising locoregional therapy for pleural malignancies. However, the combination of surgical trauma, intrathoracic hyperthermia, and cytotoxic exposure to cisplatin can trigger a complex systemic inflammatory response that resembles septic shock, vasoplegic syndrome, and major burn injury. This review proposes the concept of aseptic-thermochemical shock as a pathophysiological framework for understanding the systemic inflammatory response induced by hyperthermic intrathoracic chemotherapy and outlines a perioperative management protocol that integrates strategies from burn and sepsis care. A narrative review was conducted using PubMed, Scopus, Embase, and LILACS to identify relevant studies on hyperthermic intrathoracic chemotherapy, systemic inflammation, vasoplegic syndrome, and cisplatin nephrotoxicity. Clinical analogies with septic and burn physiology were analyzed to develop a framework for perioperative management. Hyperthermic intrathoracic chemotherapy induces a sterile thermochemical inflammatory response characterized by endothelial dysfunction, vasodilation, capillary leak, and hemodynamic instability. The proposed management strategy includes prophylactic hydration, gastric protection, and nephroprotective agents during the preoperative phase; temperature control, goal-directed fluid therapy, and selective use of methylene blue for refractory vasoplegia during the intraoperative phase; and fluid resuscitation based on modified Parkland-derived principles with hemodynamic optimization guided by Surviving Sepsis Campaign principles during the postoperative phase. These measures are intended to reduce vasoplegic and nephrotoxic complications and improve perioperative outcomes. Hyperthermic intrathoracic chemotherapy can produce a systemic inflammatory response that combines physiological features of major burns, vasoplegic syndrome, and septic shock. The proposed paradigm of "aseptic-thermochemical shock" provides a conceptual and practical basis for perioperative management. Adapting selected critical care principles from burn and sepsis medicine may support recovery and survival in patients undergoing thoracic oncological surgery.