Review Note
Last Update: 02/20/2025 12:49 AM
Current Deck: ACG Part 2::Thoracic SSU
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Commit #286229SS_TS 1.13 Discuss the anaesthetic management of the following procedures:
• Surgery for mediastinal mass
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Commit #286229Intra-op:
Biggest concerns: Airway obstruction and cardiovascular collapse
- Approach will be dependent on surgical approach:
- Diagnostic vs therapeutic
- Mediastinoscopy vs VATS vs thoracotomy vs sternotomy
- Consider LA for biopsy/high risk surgery where able
- Generally for sternotomy or thoracotomy/VATS = GA:
Airway:
- SLT or DLETT, may need AFOI with SLT then exchange for DLETT
- Rigid bronchoscopy on standby if airway compromise
- Elective cardiopulmonary bypass in high-risk cases
Breathing:
- Depends if intubation is distal to tracheobroncial obstruction, if distal IPPV ok
- A lot of resources will say spontaneous ventilation however in practice (at least at Auckland) this is never done
- Risk of worsening obstruction and venous return with IPPV
Circulation:
- Large bore IVL’s pre-induction, if SVC obstruction these need to be in the lower body
- A-line
- CVL in femoral vein if SVC obstruction to ensure drug delivery to effect site
- High risk for bleeding as venous congestion ++ and vascular tumours often invading large blood vessels, consider cell saver/rapid infusion device
- Blood should be immediately available
- Careful use of IVF - excessive administration is an independent risk related to ALI
Choice of anaesthetic:
- Consider short acting narcotics, short acting anaesthetic agents and reversible or short acting muscle relaxants
- Most texts talk about spontaneous breathing induction technique to avoid IPPV and sudden cardiovascular collapse (not practiced at ACH)
Positioning:
- Will depend of surgical technique
Deterioration intra-op:
- DDx is airway compromise vs cardiovascular collapse
- Respiratory:
- 100% FiO2
- CPAP
- Reposition - lateral, prone
- IPPV with PEEP
- OLV
- Rigid bronchoscopy - can pass beyond obstruction under direct vision and ventilate distal to obstruction, care to avoid gas trapping
- Cardiovascular:
- Fluid bolus
- Reduce depth of anaesthesia
- Reposition - prone
- Sternotomy and elevation of mass
- ECMO