Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA.
Can J Anaesth. 2011 Sep;58(9):853-9, 860-7. doi: 10.1007/s12630-011-9539-x. Epub 2011 Jul 21.
Many cases have been reported of hemodynamic and airway collapse induced by general anesthesia in patients with an anterior mediastinal mass. We examined the literature for predictors of perioperative risk, guidelines for preoperative investigations, and strategies for management of the patient with a mediastinal mass.
In patients with an anterior mediastinal mass, symptoms may range from none to severe and may include orthopnea, stridor, cyanosis, jugular vein distension, or superior vena cava syndrome. In limited case series, incidences of serious complications up to 20% were noted, but these are primarily pediatric studies with unclear relevance to adults. There is a paucity of evidence providing guidance on quantifying risk and planning the safe conduct of anesthesia. In the largest adult case series to date, intraoperative complications were associated only with the preoperative presence of a pericardial effusion. Postoperative complications were predicted by severe symptoms at presentation, tracheal compression of > 50%, and a mixed obstructive-restrictive picture on pulmonary function testing. Low-risk patients tolerate conventional general anesthesia with neuromuscular blockade and positive pressure ventilation. Those at intermediate or high risk are best managed with the maintenance of spontaneous ventilation, at least initially. Cardiopulmonary bypass remains the option of last resort.
It appears prudent to avoid general anesthesia when possible for patients at the highest risk. When general anesthesia is required, a comprehensive plan must be formulated preoperatively with the surgical team. Cardiopulmonary bypass requires time for implementation, so it should be considered early and appropriate preparations should be made prior to the initiation of anesthesia.
许多病例报告显示，在前纵隔肿块患者全身麻醉时会出现血流动力学和气道塌陷。我们查阅文献，寻找围手术期风险的预测因素、术前检查的指南以及纵隔肿块患者的管理策略。
在前纵隔肿块患者中，症状范围从无到严重不等，可能包括端坐呼吸、喘鸣、发绀、颈静脉扩张或上腔静脉综合征。在有限的病例系列中，严重并发症的发生率高达 20%，但这些主要是儿科研究，与成人的相关性不明确。目前缺乏提供量化风险和安全实施麻醉指导的证据。在迄今为止最大的成人病例系列中，术中并发症仅与术前存在心包积液有关。术后并发症可根据以下因素预测：出现严重症状、气管受压超过 50%以及肺功能测试显示混合阻塞-限制性图像。低风险患者可耐受常规全身麻醉联合神经肌肉阻滞和正压通气。中危或高危患者最好至少最初采用保留自主呼吸的方式进行管理。体外循环仍然是最后的选择。
对于风险最高的患者，似乎应尽可能避免全身麻醉。当需要全身麻醉时，必须与手术团队一起在术前制定全面的计划。体外循环需要时间来实施，因此应尽早考虑，并在开始麻醉前做好适当的准备。
