BACKGROUND

Anterior mediastinal masses involve unique problems when facing general anaesthesia. Extrinsic compression of the airway and cardiovascular structures could involve catastrophic consequences. The presence of previous conditions can associate a higher risk of severe complications, such as cardiac vessel, cardiovascular compression, tracheal compression over 50% and bronchial structure compression.

CASE REPORT

27 year old woman diagnosed with anterior mediastinal mass with paratracheal and subcarinal bilateral extension, in contact with both pleura and infiltrating the main pulmonary artery, ascendant aorta and the cava vein, with important pericardic vessel due to tumour infiltration. She was scheduled for mass biopsy. In a past broncoscopy, sedation with midazolam 1mg carried important desaturation with difficults in recovery.

She was considered a high risk patient, so general anaesthesia was discarded due to the important risk of cardiac arrest and difficult airway management. Before the surgery she obtained 25 points over 26 in anxiety Beck inventory. We explained the patient the risks of sedative options, and finally she accepted local anaesthesia and musical sedation. During the surgery, anxiety score was 3 over 26. The surgery underwent without incidences. She was discharged from hospital 3 weeks after.

DISCUSSION

All the risk factors make this case a hard challenge for the anaesthesiologist: general anaesthesia should be the last option. When these fatal complications appear in non critical procedures, the anaesthesiologist also has to deal with the existence of a potential disproportionate damage when the surgery is not an emergency. Less is more: in our case, the need of an extracorporeal circulation in case of cardiac tamponade was a plausible consequence, together with the real possibility of impossible intubation. The iatrogenic consequences are not acceptable in terms of risk/benefits in the current surgery.

LEARNING POINTS

- The detection of risk factors in an accurate preoperative evaluation is essential to plan an adequate anaesthetic approach.

- Patients with high risk of complications must be informed of the complications and, if possible, general anaesthesia must be avoided.

- Even though autonomy principle is respected, in case of fatal complications liability of the anaesthesiologist is still controversial.

09 / Less Is More: Local Anaesthesia And Musical Sedation In Young High Risk Patient With Anterior Mediastinal Mass In Non-Emergent Surgery.