Anterior Mediastinal Mass Removal
- Access
- PIV x2. Consider an arterial line for hemodynamic stability.
- Airway
- Double lumen oral ETT. Kelly clamps available (protect the ends with a bit of red rubber tubing, the kind used for stomas).
- Induction
- Standard
- Maintenance
- Gas and paralytic
- Emergence
- Awake
- Antibiotics
- Cefazolin
- Position
- Standard
- Special
- Consider the location of the mass.
Notes
If compromising SVC: may lead to SVC syndrome — place PIV in the lower extremity to ensure return to heart.
If compromising airway: consider awake fiberoptic (need to advance distal to airway obstruction).
There is concern for airway compromise/compression with induction of GA. Per Vinny Sakk, recent papers suggest GA induction with paralysis and positive-pressure ventilation can be performed safely in selected cases. In those reports, patients with airway issues were spontaneously breathing in recovery.
Myasthenia gravis: More susceptible to non-depolarizing paralytics, so be gentle. At risk for post-op respiratory failure (if pyridostigmine daily > 750 mg, BMI > 28, COPD/asthma, cannot count past 25 in one breath).