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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Anesthetic Management of a Parturient with a Large Anterior Mediastinal Mass Compressing the Great Vessels

Abstract Number: S5C-6
Abstract Type: Case Report/Case Series

Andrew S Walker MD1 ; Andrew Walker MD2; Carrie M Polin MD3

A 31 year old G2P1 female with estimated gestational age of 34 weeks presented with a 4 week history of progressively worsening dyspnea and back pain. At the time of presentation, she was unable to perform activities of daily living. On physical exam, her respiratory effort increased significantly when she was supine at less than a 45-degree angle. Due to initial concerns of a pulmonary embolus, a CT Angiogram of the chest was obtained revealing a 15 x 11.5 cm anterior mediastinal mass and a large left pleural effusion. A transthoracic echocardiogram demonstrated supravalvular pulmonic stenosis with a 62 mmHg gradient, a preserved ejection fraction, and non-definitive early signs of tamponade. The patient underwent a left thoracentesis and preliminary cytology suggested lymphoma.

An interdisciplinary meeting was held with anesthesiology, cardiology, obstetrics, cardiothoracic surgery, and oncology to discuss a patient care and delivery plan. Care plans discussed included neoadjuvant chemotherapy prior to delivery to reduce tumor burden, in turn reducing maternal risk at the time of delivery, versus delivery followed by treatment of the lymphoma. Ultimately, the decision was made to proceed with delivery prior to initiating treatment for the lymphoma due to concern for chemotherapy inducing tumor lysis syndrome, which could acutely compromise the stability of the patient and fetus. A cesarean delivery was planned, due to breech presentation of the fetus. An epidural was planned for the anesthetic management for the cesarean section. A general anesthetic was avoided in the setting of severe pulmonary stenosis and concern for airway collapse as a result of tumor compression following muscle relaxation. A spinal anesthetic was avoided because of the risk of dramatically decreasing pre-load in the setting of severe pulmonary stenosis.

Two large bore IVs and a radial arterial line were placed prior to epidural placement. An epidural was placed at L3-L4 level and incrementally bolused with 2% lidocaine with epinephrine and sodium bicarbonate until a T6 level of anesthesia was obtained. A cardiothoracic surgeon was present throughout epidural placement and cesarean delivery in case an emergent pericardiocentesis was necessary. The patient remained hemodynamically stable throughout the cesarean section. Following delivery, the infant was admitted to the NICU due to prematurity. The patient was subsequently diagnosed with B-Cell Non-Hodgkin’s lymphoma and treated under the EPOCH protocol.

Discussion: This case illustrates successful management of an obstetric patient with a large mediastinal mass. The anesthetic management should take into account the location of the mass as well as anatomy that is compressed or displaced by the mass. Because of the location of the mass in this case, our patient was likely at higher risk of cardiovascular, rather than respiratory, collapse.

SOAP 2018