Anterior Mediastinal Mass Case File

Anterior Mediastinal Mass Case File
https://medical-phd.blogspot.com/2021/03/anterior-mediastinal-mass-case-file.html
Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene
C. Toy, MD
Case 27
A 29-year-old man presented to the hospital with a 5-week history of fatigue, nonproductive cough,
increasing dyspnea, and pleuritic chest pain. He had no history of hemoptysis, night sweats, or
fevers, and his medical history was otherwise unremarkable. On physical examination, the patient
was noted to be tachypneic and dyspneic at rest, with seemingly prolonged expiration and
accessory muscle use. His blood pressure was 116/71 mm Hg, the pulse 74 bpm, the respiratory
rate 18 breaths per minute, the temperature 36.3°C, and the oxygen saturation 88% while the
patient was breathing room air. On auscultation of the chest, breath sounds were normal. Blood
chemistry and hematology values were all normal, except for hypoxemia and a mild respiratory
alkalosis (partial pressure of oxygen [PO2] = 53 mm Hg, arterial oxygen saturation [SaO 2] = 86%,
partial pressure of carbon dioxide [PCO 2] = 30 mm Hg, and pH = 7.48; fraction of inspired oxygen
[FiO2] = 1). A chest radiograph showed a small left pleural effusion with a large mass in the
anterior and middle mediastinum abutting the heart and hilar structures. Subsequent computed
tomographic examination showed a mass in the anterior mediastinum measuring 12.3 × 5.6 × 11
cm. It compressed the tracheobronchial tree posteriorly.
➤ What are the most serious outcomes in patients with a mediastinal mass?
➤ How can the risk of these complications be reduced?
➤ What is the optimal anesthetic plan?
ANSWERS TO CASE 27:

Anterior Mediastinal Mass
Summary: A 29-year-old man with a symptomatic anterior mediastinal mass undergoing diagnostic
mediastinoscopy.
➤ Most serious outcome: Airway obstruction and hemodynamic instability including cardiac

arrest, especially with the administration of general anesthesia in patients with anterior mediastinal
masses. Although the possibility for a disastrous outcome still exists, improvements in the
intraoperative management of these cases have rendered severe intraoperative respiratory or
cardiovascular collapse less likely. Major life-threatening complications now occur more frequently
postoperatively.
➤ Minimizing risks: The primary goal during general anesthesia is the maintenance of

spontaneous ventilation if at all possible. Positioning the patient either sitting and leaning forward
at a 45 degree angle, or moving from supine to lateral or prone may help prevent cardiovascular or
respiratory collapse. Cardiopulmonary bypass may also be indicated.
➤ Anesthesia plan: Preoperative studies (CT, transthoracic echocardiography) determine the

structural abnormalities and facilitate coordinated planning between the anesthesia and surgical
teams. Local anesthesia with sedation, regional anesthesia, or general anesthesia with the
maintenance of spontaneous ventilation represent appropriate anesthetic options. Of course, it is
imperative to monitor gas exchange and hemodynamics while maintaining spontaneous ventilation
until either the airway is definitively secured or the procedure is completed.
ANALYSIS
Objectives
1. Understand the complications, including respiratory and cardiovascular collapse, including the
inability to resuscitate, that can ensue on induction of general anesthesia.
2. Become acquainted with the technique for extubating a patient with a mediastinal mass.
3. Examine what have been identified as suitable methods to care for this group of patients.
Considerations
In this patient with a mediastinal mass, monitoring during surgery includes a continuous two-lead
electrocardiogram (lead II and V5), oxygen saturation, and direct arterial pressure catheter.
Anesthesia is induced with an inhalational agent such as sevoflurane, with the patient sitting at a 45
degree angle and breathing spontaneously. In contrast, an induction with intravenous agents could
well be associated with apnea. Respiration can be assisted if necessary, but tracheal intubation is
achieved without the use of neuromuscular blockade.
Consistent with the CT scan, fiberoptic bronchoscopy will likely reveal a severe (> 70%)
compression of the lumen of the lower third of the trachea. If possible, the end tracheal tube is
advanced distal to the tracheal compression under fiberoptic guidance. This will allow ventilation
of both lungs, and subsequent bronchoscopic examination. An uncomplicated left anterior
mediastinoscopy revealed a high-grade Hodgkin lymphoma at biopsy. The conclusion of the
procedure, the patient was successfully extubated awake, while again, sitting at a 45 degree angle.

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➤ How can the risk of these complications be reduced?

➤ What is the optimal anesthetic plan?

ANSWERS TO CASE 27:

➤ Most serious outcome: Airway obstruction and hemodynamic instability including cardiac

➤ Minimizing risks: The primary goal during general anesthesia is the maintenance of

➤ Anesthesia plan: Preoperative studies (CT, transthoracic echocardiography) determine the

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