Journal of Anesthesia

, Volume 24, Issue 4, pp 607–610 | Cite as

Dexmedetomidine for anesthetic management of anterior mediastinal mass

  • Basem Abdelmalak
  • Nicholas Marcanthony
  • Joseph Abdelmalak
  • Michael S. Machuzak
  • Thomas R. Gildea
  • D. John Doyle
Clinical Report

Abstract

Anesthetic management of anterior mediastinal masses (AMM) is challenging. We describe the successful anesthetic management of two patients with AMM in which dexmedetomidine was used at supra-sedative doses. Our first case was a 41-year-old man who presented with a 10 × 9 × 11 cm AMM, a pericardial effusion, compression of the right atrium, and superior vena cava syndrome. He had severe obstruction of the right mainstem bronchus, distal trachea with tumor compression, and endobronchial tumor invasion. Our second case was a 62-year-old man with tracheal and bronchial obstruction secondary to a recurrent non-small-cell lung cancer mediastinal mass. Both patients were scheduled for laser tumor debulking and treatment of the tracheal compression with a Y-stent placed through a rigid bronchoscope. Both patients were fiberoptically intubated awake under sedation using a dexmedetomidine infusion, followed by general anesthesia (mainly using higher doses of dexmedetomidine), thus maintaining spontaneous ventilation and avoiding muscle relaxation during a very stimulating procedure. The amnestic and analgesic properties of dexmedetomidine were particularly helpful. Maintaining spontaneous ventilation with dexmedetomidine as almost the sole anesthetic could be very advantageous and may reduce the risk of complete airway obstruction in the anesthetic management of AMMs.

Keywords

Mediastinal mass Dexmedetomidine Airway management 

Notes

Acknowledgments

Supported by internal funds. Dr Basem Abdelmalak receives a research grant from Aspect Medical (Newton, MA, USA) in support of other research projects.

Conflict of interest statement

Dr. Abdelmalak recently received a one time honorarium from Hospira, Inc.

References

  1. 1.
    Bittar D. Respiratory obstruction associated with induction of general anesthesia in a patient with mediastinal Hodgkin’s disease. Anesth Anal. 1975;54:399–403.CrossRefGoogle Scholar
  2. 2.
    Azizkhan RG, Dudgeon DL, Buck JR, Colombani PM, Yaster M, Nichols D, Civin C, Kramer SS, Haller JA Jr. Life-threatening airway obstruction as a complication to the management of mediastinal masses in children. J Pediatr Surg. 1985;20:816–22.CrossRefPubMedGoogle Scholar
  3. 3.
    King DR, Patrick LE, Ginn-Pease ME, McCoy KS, Klopfenstein K. Pulmonary function is compromised in children with mediastinal lymphoma. J Pediatr Surg. 1997;32:294–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Piro AJ, Weiss DR, Hellman S. Mediastinal Hodgkin’s disease: a possible danger for intubation anesthesia. Intubation danger in Hodgkin’s disease. Int J Radiat Oncol Biol Phys. 1976;1:415–9.PubMedGoogle Scholar
  5. 5.
    Ferrari LR, Bedford RF. General anesthesia prior to treatment of anterior mediastinal masses in pediatric cancer patients. Anesthesiology. 1990;72:991–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Turoff RD, Gomez GA, Berjian R, Park JJ, Priore RL, Lawrence DD, Panahon A, Douglass HA Jr. Postoperative respiratory complications in patients with Hodgkin’s disease: relationship to the size of the mediastinal tumor. Eur J Cancer Clin Oncol. 1985;21:1043–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Bechard P, Letourneau L, Lacasse Y, Cote D, Bussieres JS. Perioperative cardiorespiratory complications in adults with mediastinal mass: incidence and risk factors. Anesthesiology. 2004;100:826–34.CrossRefPubMedGoogle Scholar
  8. 8.
    Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of the patient with an anterior mediastinal mass. Anesthesiology. 1984;60:144–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol. 2007;20:1–3.CrossRefPubMedGoogle Scholar
  10. 10.
    Goh MH, Liu XY, Goh YS. Anterior mediastinal masses: an anaesthetic challenge. Anaesthesia. 1999;54:670–4.CrossRefPubMedGoogle Scholar
  11. 11.
    Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000;93:382–94.CrossRefPubMedGoogle Scholar
  12. 12.
    Scher CS, Gitlin MC. Dexmedetomidine and low-dose ketamine provide adequate sedation for awake fibreoptic intubation. Can J Anaesth. 2003;50:607–10.CrossRefPubMedGoogle Scholar
  13. 13.
    Maze M. Pharmacology and Use of Alpha-2 agonists in Anesthesia. European Society of Anesthesiologists Refresher Course. 2003; 37–43.Google Scholar
  14. 14.
    Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. J Clin Anesth. 2007;19:370–3.CrossRefPubMedGoogle Scholar
  15. 15.
    Ramsay MA, Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent. Anesthesiology. 2004;101:787–90.CrossRefPubMedGoogle Scholar
  16. 16.
    Ramsay MA, Saha D, Hebeler RF. Tracheal resection in the morbidly obese patient: the role of dexmedetomidine. J Clin Anesth. 2006;18:452–4.CrossRefPubMedGoogle Scholar
  17. 17.
    Nafiu OO, Srinivasan A, Ravanbakht J, Wu B, Lau WC. Dexmedetomidine sedation in a patient with superior vena cava syndrome and extreme needle phobia. J Cardiothorac Vasc Anesth. 2008;22:581–3.CrossRefPubMedGoogle Scholar
  18. 18.
    Tempe DK, Arya R, Dubey S, Khanna S, Tomar AS, Grover V, Nigam M, Makwane UK. Mediastinal mass resection: femorofemoral cardiopulmonary bypass before induction of anesthesia in the management of airway obstruction. J Cardiothorac Vasc Anesth. 2001;15:233–6.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2010

Authors and Affiliations

  • Basem Abdelmalak
    • 1
    • 6
  • Nicholas Marcanthony
    • 2
  • Joseph Abdelmalak
    • 2
  • Michael S. Machuzak
    • 3
  • Thomas R. Gildea
    • 4
  • D. John Doyle
    • 5
  1. 1.Section of Anesthesia for Bronchoscopic Surgery, Departments of General Anesthesiology and Outcomes ResearchAnesthesiology Institute, Cleveland ClinicClevelandUSA
  2. 2.Anesthesiology Institute, Cleveland ClinicClevelandUSA
  3. 3.Center for Major Airway Disease, Respiratory Institute and Transplant Center, Cleveland ClinicClevelandUSA
  4. 4.Section of Bronchoscopy, Respiratory Institute and Transplant Center, Cleveland ClinicClevelandUSA
  5. 5.Department of General AnesthesiologyAnesthesiology Institute, Cleveland ClinicClevelandUSA
  6. 6.Department of General Anesthesiology/E31Cleveland ClinicClevelandUSA

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