Anesthetic management for anterior mediastinal mass and mediastinoscopy: a case study

A 27-year-old white male was scheduled for a mediastinoscopy of an anterior mediastinal mass. The patient was induced with thiopental and succinylcholine, in anticipation of possible difficulty managing the airway. There was no distortion of the airway, and he was easily intubated with a No. 8.5 anode tube and given 20 mg of atracurium. The extent of tumor growth was greater than expected and, as a result, biopsies of the neck were taken without the need for mediastinoscopy. The atracurium was reversed with atropine and edrophonium. Although respirations were being assisted, the SaO2 decreased significantly, and end-tidal CO2 was greatly increased. When the drapes were removed, the patient was found to be cyanotic, with vein distention in the neck and upper extremities. All anesthetic agents were discontinued, the patient was hyperventilated with 100% oxygen, 100 mg of lidocaine was given for coughing and breath-holding, and the patient was placed in the reverse Trendelenburg position. The SaO2 then increased, and the end-tidal CO2 decreased. Respirations were spontaneous, and the patient could be extubated. The probable cause of this episode was obstruction of the superior vena cava by the anterior mediastinal mass. When the muscle relaxant was reversed, the increase in intrathoracic pressure caused the mass to compress the superior vena cava. The compression was released by placing the patient in a reverse Trendelenburg position, which caused the mass to shift. In addition to superior vena cava compression, other complications of anterior mediastinal masses include airway obstruction, distortion of anatomy, impaired cerebral circulation and myasthenic syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)