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Abstract
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Background and Aims Mediastinal masses can represent a menace to airways and great vessels when general anesthesia with endotracheal intubation is necessary for surgical procedures. Locoregional anesthesia efficiently overcomes intubation-related risks and complications when synergic blocks are performed.
Methods We present the case of a 79 years old female with a bulky 20 x 19 x 25 cm anterior solid mediastinal mass with left pleural effusion (figure 1). Diagnostic suspicion was hematologic malignancy versus thymoma but percutaneous CT-guided biopsy wasn’t conclusive. FDG PET-CT (figure 2) showed high glycolytic metabolism of the mass. Surgical biopsy was necessary to obtain adequate sample of the tumor.
Coronal views of the mediastinal mass with left pleural effusion
FDG PET-CT with glucose avidity of the mass
Results The plan was to avoid general anesthesia because of the mass related risks. Intravenous Midazolam 2 mg and Fentanest 50 mcg were used for sedation in right lateral decubitus. Under ultrasound guidance with linear high-frequency probe left T4-T5 and T6-T7 paravertebral block (figure 3) was performed with ropivacaine 7,5% 150 mg, followed by left parasternal block with ropivacaine 0,5% 10 ml between 2nd and 4th intercostal spaces in supine position. Anterior left mediastinotomy in spontaneous ventilation was performed with excellent anesthetic coverage and subsequent analgesia. Histology showed combination of T-Lymphoblastic Leukemia and thymoma.
US guided left paravertebral block with focus on probe positioning
Conclusions Anesthesia for mediastinal masses must be carefully planned because of potential severe complications. The risks are high when in supine position, under general anesthesia and mass-related symptoms prior to the procedure. Paravertebral block (PVB) and parasternal block (PSI) can produce efficient anesthesia for open biopsies and adeguate analgesia. These blocks are safe and easy to reproduce, providing valid alternatives to general anesthesia.