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Cardiothoracic Surgery |

Prone Positioning for Cardiorespiratory Collapse in an Adult Patient With Anterior Mediastinal Mass After General Anesthesia

Brian Scheele, DO; Kori Ascher, DO; Carolina De La Cuesta, MD; Mark Csete, MD
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Mount Sinai Medical Center, Miami Beach, FL


Chest. 2015;148(4_MeetingAbstracts):23A. doi:10.1378/chest.2254405
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Abstract

SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM

INTRODUCTION: Patients with an anterior mediastinal mass (AMM) are at high risk for cardiorespiratory collapse (CRC) postoperatively [1]. We present a case of prone positioning (PP) for CRC after mediastinoscopy with biopsy for an AMM. We present this case to demonstrate the use of PP to resolve CRC in patients with AMM and recommend a multidisciplinary preoperative plan (MPP) to decrease this risk in adults.

CASE PRESENTATION: A 23 year old previously healthy Indian male presented to our emergency department c/o 2 months of shortness of breath. ROS was positive for DOE, stridor, positional lightheadedness and morning facial swelling. Physical exam findings were HR 110 and decreased right-sided breath sounds. Imaging (Image 1) revealed an AMM measuring 15x10x16cm, SVC obstruction and compression of the right main pulmonary artery, veins and central airway. He underwent mediastinoscopy with biopsy, failed extubation and was transferred to our ICU. Hours after surgery he became hypotensive, with elevated peak airway pressures and hypercarbia refractory to increased ventilatory support and fluid resuscitation. CXR was unremarkable for pneumothorax, atelectasis or new infiltrate. We initiated PP for CRC with rapid normalization of peak pressures, correction of PaCO2, and resolution of hypotension (Table 1). On POD2 his hemodynamics tolerated supine positioning, on POD3 chemotherapy began and POD6 yielded successful extubation. He was discharged on POD7 with a pathological diagnosis of pure seminoma.

DISCUSSION: Severe symptoms and CT findings placed our patient at high risk and his subsequent clinical decline highlights the need for an MPP. Interventions to correct CRC in this population include avoidance of general anesthesia and maintenance of spontaneous ventilation, "rescue" positioning, placement of a reinforced ETT distal to the obstruction, rigid bronchoscopy, heliox, and cardiopulmonary bypass [2]. "Rescue" positioning in our case was achieved by PP with resolution of immediate threat to life.

CONCLUSIONS: General anesthesia can prompt CRC in patients with an AMM [1]. In children with an AMM, an MPP demonstrated favorable outcomes while minimizing morbidity and anesthetic risks [3]. In adults an MPP should include oncology, anesthesia, cardiothoracic surgery, and intensivist services. Our case demonstrates that PP can be instituted with a good outcome in a patient with an AMM. An MPP may identify those patients that would benefit from early intervention with PP.

Reference #1: Béchard P, Létourneau L, Lacasse Y, Côté, D. et al. Perioperative cardiorespiratory complications in adults with mediastinal mass. Anesthesiology,2004;100(4),826-34

Reference #2: Blank R, Souza D. Anesthetic management of patients with an anterior mediastinal mass: continuing professional development.Canadian Journal of Anesthesia.2011;58(9),853-867

Reference #3: Acker S, Linton J, Tan G. et al. A multidisciplinary approach to the management of anterior mediastinal masses in children. Journal of Pediatric Surgery.2009

DISCLOSURE: The following authors have nothing to disclose: Brian Scheele, Kori Ascher, Carolina De La Cuesta, Mark Csete

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