ANAESTHETIC CONCERNS AND MANAGEMENT OF MEDIASTINAL MASS

– Clinical presentations of patients with mediastinal mass
– Anaesthetic concerns of mediastinal mass
– Anaesthetic managements of mediastinal mass
– The role of multidisciplinary team (MDT) in the management of mediastinal mass
– Case scenario

Major Goals of Pre-anaesthesia Consultation:
1. Mass effect on airway and lungs
2. Mass effect on cardiovascular structures and circulation
3. Potential loss of awake compensatory mechanism after GA (airway, IPPV, drug-induced venodilation, position)
4. Possible surgical manipulation and resection of mass
5. Postoperative analgesia (cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopic surgery, open thoracotomy or sternotomy)

Preoperative consideration:
1.MDT meeting (anaesthesia, surgery, radiology, ENT, pathology)
2.Exact assessment of tumour size, its localization and any potential airway obstruction or SVC syndrome
3.Consider preoperative irradiation or chemotherapy
4.Risk stratification for mediastinal mass syndrome (safe, unsafe, uncertain) (Table 1 and 2)
5.Avoid preoperative sedatives
6.Consider regional anaesthesia
6.Consider anaesthetist escort for patient with position-dependent mediastinal mass syndrome
7.Adjustable operating table
8.Alternative airway and circulation management options must be provided (various size and spiral reinforced ET tubes, flexible fibreoptic and rigid bronchoscopy are recommended/ a cardiopulmonary bypass machine and presence of perfusionist are recommended in “unsafe”
9.Vascular access- large bore intravenous cannula/ CVL in lower extremity in SVC syndrome
10.Consider pulse oximetry in right arm to monitor the brachiocephalic trunk
11.To ensure safe hemodynamic and respiratory monitoring with drug and fluid/blood administration

Intraoperative consideration:

1.Airway management
– Difficult airway trolley
– ETT (reinforced ETT, microlaryngeal tube MLT, double lumen ETT)
– Awake fibreoptic intubation
– Standby rigid bronchoscope for use if loss airway patency
– Maintain spontaneous ventilation during induction and maintenance if possible
– Continuous confirmation of airway patency, oxygenation and ventilation (fibreoptic bronchoscope)

2.Hemodynamic monitoring
– Artline and CVL monitoring
– Blood product/ crystalloid/ colloids
– Induction agents with minimal hemodynamic instability (ketamine)
– Adequate volume prior to induction
– Use short-acting anaesthetic agent and opioid (remifentanil)
– Standby inotropes or vasopressor if necessary
– Dynamic parameter (respirophasic variations on systolic PPV, Flotrac)
– Transeosophageal echocardiography
– Delayed epidural activation until the mass has been resected
– Constant communication with surgeons/blood bank

Postoperative consideration:
1.“unsafe” -> transferred to ICU for aim of extubation
2.“uncertain” and “safe” -> decided depending on preop findings and intraop courses
3.Adequate analgesia given (NSAID, epidural analgesia, paravertebral block, intercostal block, intravenous PCA)
4.Look for emergency complications:
vSurgical site hemorrhage
vAirway compromise (edema, nerve damage-phrenic injury/ recurrent larnygeal nerve)

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