Perioperative Course:
On DOL4, 34w3d, patient was brought to OR for tumor resection. Patient had a pre-existing 3.5 uncuffed ETT, and all inpatient infusions were maintained, including TPN, dexmedetomedine 0.3 mcg/kg/hr, morphine 20 mcg/kg/hr, and dopamine 2.5 mcg/kg/hour. Patient was given additional 0.4mg of midazolam and 5mg of rocuronium prior to transport. In addition to existing UAC and UVC, two 22g IV’s were established in OR for access. ETT was exchanged to 3.0 cuffed ETT uneventfully under direct laryngoscopy due to leak.
General anaesthesia was maintained with oxygen/air, sevoflurane, 5 mcg increments of fentanyl, and 2 mg of rocuronium intermittently. In addition to arterial waveform and CVP, near-infrared spectroscopy (NIRS), capnography, temperature, and pulse oximetry monitoring were utilized. Via median sternotomy, with cardiopulmonary bypass on standby, the pericardium was opened and a multiloculated hemorrhagic-appearing mass measuring approximately 5 centimeters in length was revealed, densely adherent along the entire lateral aspect of the ascending aorta as well as the medial aspect of the SVC. There were multiple bouts of hemodynamic instability while the mass was being resected due to the proximity of the mass to the systemic venous connections. As a result, the patient remained on dopamine throughout the case and received liberal fluid resuscitation (25mL/kg of crystalloid) as well as 40mL/kg of pRBCs. Permissive hypotension was allowed to facilitate resection. The case did not require cardiopulmonary bypass and the chest was closed uneventfully after resection (Fig 3). She was brought to cardiac ICU intubated post operatively, and required inotropic support until post-operative day 1. She was extubated in the intensive care unit on post-operative day 2. The patient was discharged home on post-operative day 4.