Pratas Miguel, Aires Jorge, Pereira da Silva Nuno, Oliveira Tiago, Pinto Cristovão, Li Jiele, Ribeiro Ana Filipa
Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
Case Rep Anesthesiol. 2022 Feb 21;2022:3519003. doi: 10.1155/2022/3519003. eCollection 2022.
Perioperative management of patients with mediastinal masses still poses a challenge for the anesthesiologist, as the use of general anesthesia can be associated with acute perioperative cardiorespiratory impairment resulting from the mass collapsing on the airway or vascular structures. Dexmedetomidine can be used for procedural sedation due to its reversible sedative and anxiolytic properties with dose-dependent effects, while not interfering with ventilatory drive. These features are of particular interest for the perioperative management of patients with large anterior mediastinal masses. In this case, we report our anesthetic management of a 22-year-old male scheduled for anterior mediastinotomy, with a large anterior mediastinal mass, with 50% distal tracheal compression and marked collapse of the superior vena cava and brachiocephalic trunk. In the operation theatre, an infusion of dexmedetomidine was titrated to adequate anesthetic depth while keeping the patient under spontaneous ventilation with oxygen (O) supplementation and local anesthetic infiltration of the surgical site. Mediastinotomy lasted for about 30 minutes, during which the patient maintained appropriate ventilation and hemodynamic stability. No adverse events occurred perioperatively. Diagnostic procedures such as mediastinotomy for tissue biopsy are necessary to achieve a histological diagnosis. High-risk patients may present with severe postural symptoms, stridor, cyanosis, and radiological evidence of more than 50% airway obstruction, tracheal compression with bronchial compression, pericardial effusion, or superior vena cava syndrome. Relaxation of bronchial smooth muscles under general anesthesia increases the risk of airway obstruction. In this case, with the use of dexmedetomidine combined with local anesthetic infiltration, spontaneous ventilation and muscle tone were preserved, decreasing the probability of intraoperative complications. It is our opinion that dexmedetomidine combined with local anesthetic infiltration can be a safe option for procedural sedation in patients presenting with high-risk anterior mediastinal masses for mediastinotomy.
纵隔肿物患者的围手术期管理对麻醉医生来说仍然是一项挑战，因为全身麻醉的使用可能会因肿物压迫气道或血管结构而导致围手术期急性心肺功能损害。右美托咪定因其具有可逆的镇静和抗焦虑特性且作用呈剂量依赖性，同时不干扰通气驱动，可用于操作过程中的镇静。这些特性对于前纵隔大肿物患者的围手术期管理尤为重要。在此，我们报告一例22岁男性患者的麻醉管理情况，该患者计划行前纵隔切开术，患有前纵隔大肿物，气管远端受压50%，上腔静脉和头臂干明显塌陷。在手术室，输注右美托咪定以滴定至适当的麻醉深度，同时让患者在补充氧气（O）的情况下自主通气，并对手术部位进行局部麻醉浸润。纵隔切开术持续约30分钟，在此期间患者维持了适当的通气和血流动力学稳定。围手术期未发生不良事件。诸如纵隔切开术取组织活检等诊断程序对于获得组织学诊断是必要的。高危患者可能出现严重的体位性症状、喘鸣、发绀，以及气道梗阻超过50%、气管受压合并支气管受压、心包积液或上腔静脉综合征的影像学证据。全身麻醉下支气管平滑肌松弛会增加气道梗阻的风险。在本病例中，通过使用右美托咪定联合局部麻醉浸润，保留了自主通气和肌肉张力，降低了术中并发症的发生概率。我们认为，右美托咪定联合局部麻醉浸润对于因前纵隔大肿物而行纵隔切开术的高危患者的操作过程镇静可能是一种安全的选择。
