Pregnant Patient with a Large Anterior Mediastinal Lymphoma
Abstract Number: F 45
Abstract Type: Case Report/Case Series
Perioperative management of the patient with an anterior mediastinal mass (AMM) is an anesthetic challenge due to tracheobronchial tree obstruction, compression of the pulmonary artery and heart, and superior venal caval syndrome (SVCS)(1). We describe the management of a patient who is 14 weeks pregnant with a massive AMM causing SVCS requiring thoracic biopsy and later, dilatation and curettage (D&C) in order to begin chemotherapy.
The patient is a 31 y.o. G1P0 at 14 weeks whose physical exam revealed massive engorgement of chest veins, neck and facial swelling. Chest CT showed a large AMM extending to the anterior chest wall with compression of the carina and both mainstem bronchi. The SVC was obliterated by the surrounding mass. Incisional biopsy of the mass was performed under ketamine and local infiltration with lidocaine. Ketamine 25 mg was given followed by 10-20 mg q10min prn for a total of 160mg. Later that evening, she reported disturbing nightmares.
Surgical pathology showed primary large B-cell lymphoma. In order to begin chemotherapy, the decision to terminate pregnancy was made. The patient returned to the operating room four days later to have a D&C. The patient was still anxious and was adamant that she not receive ketamine again. A saddle block with concurrent dexmedetomidine (DEX) infusion and midazolam sedation was planned. Hyperbaric spinal bupivacaine 9 mg and DEX 1mcg/kg i.v. over 30 minutes were administered. A total of 7 mg of midazolam was given. As the saddle block was too low, paracervical block was also required. Sedation was maintained with DEX 0.33 mcg/kg/hr. The patient maintained spontaneous ventilation and the case was uneventful.
These two anesthetics highlighted several issues. While spontaneous ventilation should be maintained (2) and ketamine is a reasonable choice, its psychotropic effects were very unpleasant for the patient. Avoiding midazolam because of the pregnancy may also be questioned. DEX may be the preferred method of IV sedation due to its lack of neuropsychiatric side effects in this population. DEX also has a very safe respiratory profile and does not exhibit psychomotor effects associated with ketamine. However, DEX can cause hypotension and bradycardia, both of which would be undesirable in a patient with SVCS.
1. Buvanendran, A., et al Anesth Analg, 2004. 98(4): p. 1160-1163.
2. Chan, Y., Anesthesiology, 2001. 94(1): 167-169.