La prise en charge de l’anesthésie des patients avec une masse médiastinale antérieure

Abstract

Purpose Many cases have been reported of hemodynamic and airway collapse induced by general anesthesia in patients with an anterior mediastinal mass. We examined the literature for predictors of perioperative risk, guidelines for preoperative investigations, and strategies for management of the patient with a mediastinal mass. Principal findings In patients with an anterior mediastinal mass, symptoms may range from none to severe and may include orthopnea, stridor, cyanosis, jugular vein distension, or superior vena cava syndrome. In limited case series, incidences of serious complications up to 20% were noted, but these are primarily pediatric studies with unclear relevance to adults. There is a paucity of evidence providing guidance on quantifying risk and planning the safe conduct of anesthesia. In the largest adult case series to date, intraoperative complications were associated only with the preoperative presence of a pericardial effusion. Postoperative complications were predicted by severe symptoms at presentation, tracheal compression of [ 50%, and a mixed obstructive-restrictive picture on pulmonary function testing. Low-risk patients tolerate conventional general anesthesia with neuromuscular blockade and positive pressure ventilation. Those at intermediate or high risk are best managed with the maintenance of spontaneous ventilation, at least initially. Cardiopulmonary bypass remains the option of last resort. Conclusions It appears prudent to avoid general anesthesia when possible for patients at the highest risk. When general anesthesia is required, a comprehensive plan must be formulated preoperatively with the surgical team. Cardiopulmonary bypass requires time for implementation, so it should be considered early and appropriate preparations should be made prior to the initiation of anesthesia.

Anterior Mediastinaland Thyroid Mass in a Patient for Fracture Humerus Surgery: an Anesthetic’s Challenge

“…Patients can be categorised as high risk if tracheal compression>50% or has associated bronchial compression, pericardial effusion or superior vena cava syndrome [6][7], Intermediate risk if tracheal compression<50% and low risk if no significant compression of structures. [6,7] The major goal of the preanesthesia consultation in patients with mediastinal mass coming for other surgery is to estimate the presence and degree of obstruction of the tracheobronchial tree and hemodynamic instability due to mass effect on major cardiovascular structures and circulation. Serious consideration should be given to avoiding general anaesthesia and possible adverse consequences of anesthetic induction due to loss of the awake patient's compensatory mechanisms.…”

Management of large mediastinal masses: surgical and anesthesiological considerations

“…Patients with large mediastinal masses pose significant anesthesiological challenges due to the possible occurrence of MMS (3,47). Prior to definitive surgical resection, a thorough perioperative plan should be made between the surgeon and anaesthesiologist (3,47,48).…”

“…Prior to definitive surgical resection, a thorough perioperative plan should be made between the surgeon and anaesthesiologist (3,47,48). Preoperative risk assessment by the anesthesiologist is essential, based on clinical, functional, bronchoscopic, and radiological data, with emphasis on the anatomical details of the tumor and its relation with the surroundings.…”

“…This can be performed in various positions of the operating table in order to further determine the optimal rescue position. Finally, the use of short-acting medications is recommended for prompt and precise control of the level of general anesthesia (3,47).…”

Anesthetic Management of a Patient With Central Airway Compression Due to Posterior Mediastinal Mass

“…The literature is focused mostly on anesthetic management of patients with anterior mediastinal masses, which have well documented cases of respiratory or cardiovascular collapse during anesthesia and in postoperative period 1 . Masses in the posterior mediastinum have been regarded to carry a significantly lower risk.…”