Anesthetic Management of Nasopharyngeal Angiofibroma Resection with Carotid Invasion in a Pediatric Patient

Abstract

The nasopharyngeal angiofibroma is an aggressive, vascular tumor that may represent a challenge for the anesthesiologist by the risk of profuse bleeding. We report the case of a 13 years old, 52 kg, ASA1, who was scheduled for the resection of an angiofibroma invading facial sinuses and internal carotid artery, and submitted to external carotid and internal maxillary arteries embolization one day before surgery. Mallampati 2, previous successful intubation reported. Induction was made with propofol, fentanyl, lidocaine and rocuronium, followed by intubation by direct laringoscopy. Sevoflurane and remifentanyl were used for maintenance. Central venous access and arterial catheterization were provided. Inicial arterial gasometry was normal. During tumor resection close to the ethmoidal cells, there was profuse bleeding that required intensive volemic resuscitation and hemotransfusion. The cavernous part of the angiofibroma was resected by a neurosurgery team. During the whole procedure, the patient received 3500 ml of Saline Solution 0.9%, 4000 ml of RL, 1000 ml of hydroxyethyl starch, four RBC units, two plasma units and 4 platelets units. Serial arterial blood gas analysis revealed Hb = 6 g/dL as the minor value of hemoglobin and pH was physiological all the time. Fenylephrine, adrenaline and noradrenaline were infused. Even after the massive volume restitution, responsiveness to hydration was verified by the delta pulse pressure curve. Total diuresis was 300 ml. The total duration of the procedure was 9 hours. The patient was sent to the ICU after a tracheostomy. Transthoracic US revealed collapsed cava vein leading to new volume resuscitation.