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Anesthetic Management of a Pregnant patient with a Mediastinal mass
Abstract Number: SU-64
Abstract Type: Case Report/Case Series
Introduction: Mediastinal masses pose unique challenges for the anesthesiologist and are rare in pregnancy (1:1000-6000); most commonly due to Hodgkin’s Lymphoma. We present an unfortunate case of end stage breast cancer with metastatic involvement of the mediastinum.
Case Report: A 32 yo G1P0 at 25.3 WGA presented with stage IV breast cancer. Metastasis to the manubrium, lungs, brachial plexus, and mediastinum involved compression of the great vessels, bronchi and left atrium. Notably, there was 50% compression of the left and right main stem bronchi and 90% compression of the bronchus intermedius requiring palliative stenting due to post obstructive pneumonia. The patient was therapeutically anticoagulated on a heparin infusion for a pulmonary embolus. She required high doses of opioids for extreme pain from metastasis to her sternum and brachial plexus. On ICU admission, the patient was tachypneic and orthopneic on 2L O2, unable to recline more than 30 degrees. She was tachycardic with normal range blood pressures. Continuous fetal monitoring was reassuring. However, at 26.4 WGA the patient developed increasing O2 requirements, worsening dyspnea, elevated blood pressures and proteinuria. The baby had intermittent spontaneous repetitive decels and a non-urgent cesarean delivery was planned. The patient’s heparin drip was held and coagulation studies normalized. A radial arterial line and upper and lower extremity 16 gauge IVs were placed. A 19 gauge spinal catheter was positioned after intentional dural puncture. Graduated doses of both hyperbaric and isobaric bupivacaine were given to obtain a T4 sensory level and the patient tolerated a semi-recumbent position for delivery of a 0.78kg female. The patient’s postop course was complicated by pain management and palliative measures and she passed away two weeks post-partum.
Discussion: Presenting symptoms of mediastinal mass often include dyspnea, orthopnea, chest pain, cough, SVC syndrome, hoarseness or syncope. OB literature supports delivery by cesarean in a planned setting whenever possible. Maintenance of spontaneous ventilation is advocated when GETA is required, although cardiopulmonary collapse has been described despite spontaneous ventilation. Epidural and CSE techniques have been reported and we present a continuous spinal as another anesthetic option. A multidisciplinary approach to the care of these patients is crucial; availability of rigid bronchoscopy and preparation and/or cannulation for potential cardiopulmonary bypass may be warranted for some cases necessitating early consultation with pulmonary and cardiothoracic surgical colleagues.
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