2024 FSA Podium and Poster Abstracts

P061: HEAVY ON THE HEART: A MEDIASTINAL MASS IN EMERGENCY GENERAL SURGERY
Angela Bott, DO, DC; Ryan Parker, MD, PhD; University of Florida

Background: The anesthetic care of patients with mediastinal masses requires an understanding of the underlying pathology, anatomical relationships, and physiological consequences of mass effect. Factors such as mass size, location, and the potential for airway compromise significantly influence anesthetic planning and intraoperative management. A 57-year-old female presented to an outside facility with abdominal pain, tachycardia, tachypnea, and hypotension. She was able to undergo imaging, which showed free air in the abdomen and an incidental mediastinal mass surrounding the left pulmonary artery. She was transferred to UF Health for an emergent exploratory laparotomy for a suspected hollow viscus perforation. She was altered on arrival, and due to her deteriorating clinical condition, required a general anesthetic for abdominal sepsis.

Methods: Our anesthetic plan was discussed with the acute care surgical team and the on-call cardiothoracic surgeon. An ECMO circuit was primed, placed outside the operating room, and a perfusionist was available. The patient was placed in reverse Trendelenburg with the head of the bed elevated 45 degrees. Prior to induction, a left femoral 8 Fr double lumen central line and right femoral 5 Fr arterial line were placed to facilitate emergent ECMO access. The patient underwent mask induction facilitated by 50 mg of ketamine, and a 7.0 Hi-Lo Evac endotracheal tube was placed during spontaneous ventilation. The surgical team repaired a gastric perforation under spontaneous ventilation, and the patient was taken back to the ICU breathing spontaneously with an open abdomen. She returned to the OR on post-op day 1 for closure and was extubated.

Discussion: The anesthetic challenges with mediastinal masses are well documented, and appropriate care requires an understanding of the underlying pathology, anatomical relationships, and physiological consequences of mass effect. Our most significant concern in this case was the lesion’s relationship to the right pulmonary artery and the potential for immediate right ventricular failure with a standard induction. Strategies to consider during cases for mediastinal masses include awake fiberoptic intubation, maintaining spontaneous ventilation, avoiding paralytics, and elective cardiopulmonary bypass in extreme cases. Our patient presented for an emergent laparotomy in the presence of a known mediastinal mass, and given her sepsis, declining respiratory status, and need for exploratory laparotomy, required a general anesthetic. With the understanding of the surgical team, we were able to optimize our anesthetic in this case to avoid right heart failure.