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Anesthetic Management of a Parturient with an Anterior Mediastinal Mass
Abstract Number: RF3BC-286
Abstract Type: Case Report Case Series
A 27 year old G1P0 woman with a history of Hodgkin’s lymphoma at 35.6 weeks of gestation was transferred to our institution for delivery planning. She had been in remission for three years, however it recurred during this pregnancy and she developed a pericardial effusion requiring a pericardial window two months prior. She developed mild right neck and face edema, persistent dry cough, and her functional status worsened from NYHA class II to III. Chest imaging showed a 6.1 x 8.6 x 8.0 cm anterior mediastinal mass compressing the superior vena cava and the brachiocephalic vein. Echocardiogram showed preserved biventricular function with trace pericardial effusion. EKG showed sinus tachycardia.
The case was discussed with a multidisciplinary team that included OB, OB anesthesia, cardiac anesthesia, cardiothoracic surgery, hematology-oncology and ECMO teams. The case was scheduled in the main operating room given the immediate availability of resources and support personnel. Modified combined spinal epidural anesthesia was planned; cardiac anesthesia and ECMO were available in case of conversion to general anesthesia. Peripheral intravenous access included 16g and 20g in the upper extremities and 18g in the left foot. A radial arterial line was placed. Intrathecal medication included 3.75 mg of 0.75% hyperbaric bupivacaine, 15 mcg fentanyl, and 100 mcg morphine. A total of 380 mg of 2% lidocaine were slowly titrated through the epidural catheter to obtain an adequate anesthetic level. Femoral arterial (16g) and venous (6 Fr) introducers were placed for rapid access in case emergent ECMO was required. Intraoperative course was uneventful.
The primary concern for this case was the risk of cardiovascular collapse and impossibility to ventilate due to distal airway extrinsic obstruction if general anesthesia was needed. Concerns for neuraxial anesthesia included changes in respiratory mechanics secondary to a T4 level block with already compromised lung function, as well as hemodynamic stability due to vascular compression. ECMO has been described as the strategy of choice to optimize gas exchange in patients with large anterior mediastinal masses. For pregnant patients, intraoperative emergent cannulation may be more challenging due to the gravid uterus and surgery site. This case highlights the value of prophylactic femoral vascular access as a route to guide emergent ECMO cannulation. No guidelines are available on the management of parturients with anterior mediastinal mases and case reports vary on their anesthetic approach. The anesthetic plan must be elaborated on a case by case basis.
Int J Obstet Anesth. (2018) Aug; 35:99-103
JA Clinical Reports (2017) 3:28
Anesthesia (1999) 54: 670-674