Anesthetic Risk with Large Mediastinal Masses: A Management Framework Based on a Systematic Review

Anesthesia administered to a patient with a large mediastinal mass engenders concern that it may precipitate catastrophic acute hemodynamic or respiratory decompensation. A review of the available evidence is needed to define the degree of risk, mechanisms, and preventative or reactive interventions to mitigate the risk.

A systematic review of the PubMed database was conducted of studies involving adults with large mediastinal masses undergoing a procedure or anesthesia; all types of publications were included that provided data regarding risks, mechanisms, or techniques to address potential decompensation. This literature involves primarily case reports and small retrospective series; no quality assessment was deemed appropriate. Evidence was synthesized according to the consensus judgment of the writing panel.

Categories of low-, moderate-, high-, and very-high-risk emerged from review of the 72 included studies, based on the degree of symptoms, mass/chest ratio, and degree of airway and/or vascular compression. This streamlines the preparation needed-minimal for low-risk and more extensive for higher-risk. Assessment of the impact of physiologic derangement stemming from the anatomic compression in individual patients provides a framework for anesthetic management, and back-up plans should decompensation occur.

Despite limitations in the evidence inherent to a topic involving an uncommon but serious event, a framework was developed to streamline preparation for and management of patients with a large mediastinal mass requiring anesthesia in a rational manner.