Anesthesia for Patients with Mediastinal Masses

Abstract

Patients with mediastinal masses can develop major airway and cardiovascular compression under general anesthesia, which could be fatal in nature. The key to management of these patients lies in early recognition of high-risk features and formulation of an anesthetic plan appropriate for the severity of symptoms. High-risk features include respiratory symptoms that are worsened in the supine position, such as orthopnea and increased cough, superior vena cava syndrome, pericardial effusion, and evidence of airway or cardiovascular compression on CT imaging. Knowledge of the anatomical location of the mass, as well as its relationship to vital cardiorespiratory structures, careful preoperative assessment, meticulous planning in conjunction with the surgeon, and preparation for possible perioperative complications are paramount in successful management of these patients. Diagnostic procedures should be performed under local anesthesia whenever feasible. If general anesthesia is required, induction should proceed in a stepwise fashion with confirmation of adequate ventilation and circulation before proceeding to the next step. Strategies for airway management include awake fiber-optic assessment of dynamic obstruction, intubation distal to airway compression, maintenance of spontaneous ventilation, and avoidance of muscle relaxation. Management of acute airway obstruction or cardiovascular collapse may include advancing tube beyond obstruction, repositioning patient, resumption of previously tolerated state, rigid bronchoscopy, and initiation of cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO). Preinduction CPB and ECMO should be considered in extremely high-risk patients as rescue CPB may not be established rapidly enough in acute airway or cardiovascular collapse to prevent anoxic consequences.