ECMO and adult mediastinal masses

Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Local Anesthetic Infiltration, Awake Veno-Venous Extracorporeal Membrane Oxygenation, and Airway Management for Resection of a Giant Mediastinal Cyst: A Narrative Review and Case Report

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed.

Breath on the Brink: Navigating Anaesthesia Management in a Case With a Mediastinal Mass

Mediastinal teratomas are rare, often asymptomatic, but clinically significant neoplasms that can manifest with a spectrum of symptoms, frequently attributed to the compression of surrounding critical anatomical structures. Here, we present the case of a 19-year-old male with respiratory distress and chest pain attributed to a large anterior mediastinal mass, ultimately diagnosed as a benign mature teratoma of the thymus. Radiological imaging revealed a large, partially cystic mass compressing the pulmonary arteries, aortic arch, and left main bronchus. Surgical excision was deemed necessary due to symptomatic presentation. Anaesthesia management during mediastinal mass excision posed significant challenges, with prompt sternotomy due to ventilation difficulties after induction. Immediate decompression of the mass improved ventilation and saturation. Despite postoperative complications, including pulmonary leaks necessitating tracheostomy, the patient achieved significant recovery. Anaesthesia strategy was to prioritise avoiding muscle relaxants and maintaining spontaneous ventilation to mitigate airway collapse and hemodynamic instability during induction. Collaboration between anaesthesia, surgical, and intensive care teams is vital for comprehensive preoperative assessment, intraoperative readiness, and postoperative care. This case underscores the importance of interdisciplinary collaboration and meticulous planning to optimise outcomes in patients undergoing surgery for mediastinal teratomas.

Extracorporeal membrane oxygenation bridging for chemotherapy in obstructing mediastinal mass after cardiopulmonary arrest

BACKGROUND

In a sedated patient, airway compression by a large mediastinal mass can cause acute fatal cardiopulmonary arrest. Extracorporeal membrane oxygenation (ECMO) has been investigated to protect the airway and provided cardiopulmonary stability. The use of ECMO in the management of mediastinal masses was reported, however, the management complicated by cardiopulmonary arrest is poorly documented.

CASE PRESENTATION

32-year-old female presented with acute onset of left arm swelling and subacute onset of dry cough. Further investigation showed a deep venous thrombosis in left upper extremity as well as a large mediastinal mass. She underwent mediastinoscopy with biopsy of the mass which was complicated by cardiopulmonary arrest secondary to airway obstruction by the mediastinal mass. Venoarterial ECMO was initiated, while concurrently treating with a chemotherapy. The mediastinal mass responded to the chemotherapy and reduced in size during 2 days of ECMO support. She was extubated successfully and decannulated after 2 days of ECMO and discharged later.

CONCLUSIONS

Extracorporeal membrane oxygenation can serve as a viable strategy to facilitate cardiopulmonary support while concurrently treating the tumor with chemotherapy, ultimately allowing for the recovery of cardiopulmonary function, and achieving satisfactory outcomes.

Challenges and pitfalls in the perioperative management of mediastinal mass syndrome: an up-to-date review

The perioperative management of patients undergoing mediastinal mass operations presents a persistent challenge across multiple clinical specialties. General anesthesia administration further increases the risk of perioperative cardiorespiratory decompensation. The interdisciplinary team plays a crucial role in ensuring a safe perioperative period. However, due to the rarity and variability of mediastinal mass syndromes, specific management protocols are lacking. This review aims to outline the multitude of challenges and pitfalls encountered during perioperative management in patients with the mediastinal mass syndrome. We describe diagnostic evaluation, preoperative optimization, intraoperative considerations, and postoperative care strategies, emphasizing the paramount significance of a multidisciplinary approach and personalized treatment plans. Preoperative multidisciplinary discussions, meticulous anesthetic management, and well-established protocols for emergency situations are pivotal to ensuring patient safety. Healthcare providers involved in the care of patients with mediastinal mass syndrome must grasp these challenges and pitfalls, enabling them to deliver safe and effective perioperative management.

Perioperative strategies and management of giant anterior mediastinal tumors: a narrative review

Background and Objective

Giant anterior mediastinal tumors sometimes may cause circulatory collapse and respiratory failure, known as mediastinal mass syndrome (MMS). The prediction and prevention of MMS is challenging. The aim of this study is to summarize the evaluation methods for MMS and formulate treatment strategies for giant anterior mediastinal tumors.

Methods

We performed a thorough analysis of recent international literature on giant anterior mediastinal tumors (>10 cm in diameter) and MMS published in the PubMed database. The search spanned the duration of the preceding 10 years from August 19, 2023, and only studies published in English were included.

Key Content and Findings

Mature teratomas and liposarcomas are the most common giant anterior mediastinal tumors and MMS develops most frequently in case of malignant lymphomas. Here, we propose a new treatment strategy for giant anterior mediastinal tumors. Based on imaging findings, giant anterior mediastinal tumors can be classified as cystic or solid and further blood investigation data are useful for a definitive diagnosis. When malignant lymphoma or malignant germ cell tumor is highly suspected, the first choice of treatment is not surgery but chemotherapy and radiotherapy. Moreover, image-guided drainage may be effective if giant cystic anterior tumors develop into MMS. The risk classification of MMS is important for treating giant anterior mediastinal tumors. If the MMS risk classification is 'unsafe' or 'uncertain', the intraoperative management deserves special attention. The surgical approach should however be based on tumor localization and invasion of surrounding tissues. Multidisciplinary team coordination is indispensable in the treatment of giant anterior mediastinal tumors.

Conclusions

When giant anterior mediastinal tumors are encountered, it is important to follow the appropriate treatment strategy, focusing on the development of MMS based on imaging findings and symptoms.

Anesthetic considerations in interventional pulmonology

PURPOSE OF REVIEW

In this review, we highlight the important anesthetic consideration that relate to interventional bronchoscopic procedures for the management of central airway obstruction due to anterior mediastinal masses, endoluminal endobronchial obstruction, peripheral bronchoscopy for diagnosis and treatment of lung nodules, bronchoscopic lung volume reduction and medical pleuroscopy for diagnosis and management of pleural diseases.

RECENT FINDINGS

The advent of the field of Interventional Pulmonology has allowed for minimally invasive options for patients with a wide range of lung diseases which at times have replaced more invasive surgical procedures. Ongoing research has shed light on advancement in anesthetic techniques and management strategies that have increased the safety during peri-operative management during these complex procedures. Current evidence focusing on the anesthetic techniques is presented here.

SUMMARY

The field of Interventional Pulmonology requires a tailored anesthetic approach. Recent advancements and ongoing research have focused on expanding the partnership between the anesthesiologist and interventional pulmonologists which has led to improved outcomes for patients undergoing these procedures.

[Risky confirmation of a diagnosis: case series of three female patients with mediastinal mass syndrome]

Mediastinal mass syndrome (MMS) is a life-threatening complication of anesthesia for which prevention and treatment are a complication-prone interdisciplinary task. Clinical symptoms vary from asymptomatic patients up to life-threatening cardiorespiratory impairments, depending on the extent and size of a mediastinal tumor as well as the involvement of corresponding anatomical structures. Especially in the context of sedation or general anesthesia, there is a considerable risk of acute cardiopulmonary or respiratory decompensation related to tumor-induced compression of central blood vessels or even the large airways, which may result in severe complications, including death. In this case series three female patients are presented, who were each referred to this hospital with a mediastinal tumor for interventional or surgical confirmation of the diagnosis. Based on the case histories, characteristic complications are demonstrated and strategies to avoid possible adverse events of MMS are discussed. The specific anesthesiological requirements for MMS, the safety aspects of the choice of surgical and anesthesia procedures, circulatory and airway management for the required single-lung ventilation, and various aspects of the selection of the anesthetic agents are discussed in this case series.

Rescue computed tomography-guided drainage of a giant mediastinal mature teratoma causing airway obstruction prior to surgical resection: a case report

BACKGROUND

Giant mediastinal mature teratomas may cause airway obstruction or decreased venous return due to the mass effect. Preoperative stabilization of the respiratory and circulatory systems is important for perioperative management to safely perform surgery, including general anesthesia. However, to the best of our knowledge, there are only a few reports regarding the preoperative computed tomography (CT)-guided drainage of mediastinal tumors.

CASE PRESENTATION

A 30-year-old woman was admitted to the emergency room with sudden dyspnea. CT findings revealed a giant cystic mass in the anterior mediastinum compressing the trachea and the right main bronchus. The patient was intubated and CT-guided drainage of the fluid content of the cyst was performed to decompress the airway obstruction. Thereafter, the mediastinal tumor was resected during elective surgery and pathologically diagnosed as a mature teratoma.

CONCLUSIONS

Rescue preoperative CT-guided drainage of a giant mediastinal mature teratoma allowed safe general anesthesia and surgery by releasing the airway obstruction.

The anesthetic management and the role of extracorporeal membrane oxygenation for giant mediastinal tumor surgery

Mediastinal tumors are a remarkably diverse category. They include malignant and benign forms with different rates of disease progression and tissue invasion. Anesthesiologists may encounter significant difficulties in managing patients with giant mediastinal tumors due to the non-negligible occurrence of severe cardiorespiratory collapse. Respiratory complications ensue from the compression of the airways induced by the mediastinal mass: the compressive effects may be exacerbated by positioning or anesthesia induction. Furthermore, the compression or invasion of major vessels may elicit acute cardiovascular collapse. The specter of sudden cardiorespiratory deterioration should lead the anesthesiologist to careful planning: acknowledging clinical and radiological signs that may presage an increased risk of life-threatening complications is of pivotal importance. This review aims to present a strategy for treating patients with mediastinal masses, starting with the pathophysiological elements and moving through preoperative care, intraoperative behavior, and the recovery period. We will also focus on respiratory and cardiovascular issues, emphasizing the need for extracorporeal membrane oxygenation (ECMO) as a rescue and crucial component of the anesthesia strategy. Understanding the physiological alterations after anesthesia induction can aid in identifying and treating potential problems. In addition, we attempted to offer insight into multimodal anesthesia and analgesia management: we emphasize the importance of a thorough preoperative assessment and the need for reviewing extracorporeal support not just a resuscitative strategy but as an integrated component of the perioperative care.

Rescue extracorporeal membrane oxygenation for massive anterior mediastinal masses

The management of massive anterior mediastinal masses (AMM) is challenging. With the burgeoning role of extracorporeal membrane oxygenation support (ECMO) beyond the confines of salvage therapy, more trained clinicians are adopting it as a bridge for high-risk procedures or situations where temporary respiratory or cardiac support is required. We report our experience with using ECMO in the management of massive AMM in this case series of three patients sharing their clinical details and the lessons learned from them.