Perioperative Management of a Patient with Large Anterior Mediastinal Mass and Cardiopulmonary Compromise: An Updated Algorithm

INTRODUCTION Patients who present with an anterior mediastinal mass (AMM) pose complex risks for the anesthesiologist to consider. While AMMs are quite rare, especially in the adult patient population, they are related most commonly to lymphoma, thymoma, germ cell tumor, granuloma, bronchogenic carcinoma, thyroid tumors, bronchogenic cyst, and cystic hygromas, in order of frequency.1,2 Since the 1970s, intraoperative complication rates of 7 20% have been reported, ranging from mild hypoxia and hypotension to complete cardiovascular collapse, airway compression, and death.3,4 When the best practices for anesthetic management of AMM’s are adhered to, including maintenance of spontaneous ventilation and avoidance of supine positioning, mortality remains relatively low, ranging from 0.3 1.1%.5 However, some of these complications may be unavoidable despite adhering to standard practices for perioperative AMM management and require appropriate preparation and time-critical intervention to avoid serious injury or death.4 We present a brief overview of the important principles and practices concerning the management of AMM and suggest an updated algorithm with emphasis on preoperative risk stratification. Furthermore, we describe a unique case of significant hypoxemia with normotension in the setting of severe contralateral tracheobronchial and pulmonary artery compression to illustrate these points.