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///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Anesthetic Management for L&D of a Parturient with Severe Fibrosing Mediastinitis

Abstract Number: 179
Abstract Type: Case Report/Case Series

Ravpreet S Gill M.D.1 ; Jaya Ramanathan M.D.2

INTRODUCTION: Fibrosing mediastinitis involves occlusion of the pulmonary vasculature and airway structures. There is minimal experience with severe fibrosing mediastinitis and pregnancy. We present the anesthetic management of a parturient who presented with fibrosing mediastinitis.

CASE: A 31 y.o. G6P5 at 38 wk. gest. age presented for anesthesia consultation prior to induction of labor. PMH: HTN, TIA in 2004, asthma, morbid obesity and fibrosing mediastinitis. She was noted to have progressively worsening dyspnea for last 2 months at rest and even in the sitting position. She also had severe orthopnea, and frequently slept sitting on a couch. The fibrosing mediastinitis was diagnosed in 1/07. CT scan showed significant stenosis of her left airway with a left main bronchus measuring 2.5 mm. VQ scan showed 8% perfusion of the left lung. There was no tracheal stenosis or deviation, no pulm hypertension and no involvement of the right lung or the great vessels. The pulmonologist expressed concern about left bronchial airway obstruction due to secretions if she required GA. He did not believe she could be optimized further, but suggested giving frequent bronchodilator nebs during L&D, even if she was not wheezing.

Pt.s asthma was poorly controlled. She was not taking any meds for her HTN. ECHO revealed LVH, EF>60%.

Careful questioning revealed that the pt. was pregnant at the time she was diagnosed in 1/07, and had a SVD in 7/07 under epidural without difficulty. Her SOB was worst in the supine position. There was slightly less SOB in the left lateral position, and the least in the right lateral position.

Airway exam: nl. Pulm: No wheezing, decreased air entry at b/l bases, L>R.

A multi-disciplinary discussion was held to discuss the management plan. On the day of induction the pt. received epidural analgesia with 0.2% ropivacine and was started on q1h albuterol nebs. She tolerated L&D well, and 13 hours later had a SVD.

DISCUSSION: Fibrosing mediastinitis can obstruct the pulmonary vasculature and airway structures. The most common cause is an exaggerated immune response to Histoplasma infection. Prevalence information is difficult to obtain. There is minimal experience with fibrosing mediastinitis and pregnancy. Treatments include tamoxifen, prednisone, NSAIDs, and immunosuppressants. There is not good data about the effectiveness of these treatments. The mortality rates for fibrosing mediastinitis have been reported as high as 30% and are typically the result of infection, hemoptysis or involvement of the cardiac musculature.

Benefits of neuraxial anesthesia include minimizing hyperventilation due to pain, preventing the need for IV narcotics, and avoidance of airway instrumentation. A multi-disciplinary discussion is important in the management of these complicated patients. If GA is used, the anesthesiologist must be prepared to deal with difficult ventilation, and the possible need for post-op mechanical ventilation.

SOAP 2010