Discussion:
Anaesthetic management of an intrapericardial tumor can present a
serious challenge for the anaesthesiologist. Our current anaesthetic
experience is predominately based on case reports. Teratomas can be
associated with mass effect and pericardial effusions resulting in
cardiac compression and respiratory distress after birth. After
diagnosis, the typical treatment of choice is surgical resection.
For preoperative planning, it is important to obtain two-dimensional
echocardiography as well as magnetic resonance imaging for larger tumors
to elucidate the tumor’s involvement with adjacent structures.
Determining the ability to separate the mass from vital structures, such
as the great vessels and airway, is essential for anaesthetic and
surgical planning. In our patient’s case, MRI/MRA as well as
2-Dimensional echo were all obtained during preoperative planning.
In patients
with mass effect on the respiratory tree, the goal of preventing
respiratory collapse is achieved by performing intubation while the
patient is ventilating spontaneously. Depending on location of tumor,
airway obstruction and hemodynamic collapse may still occur, which may
need to be alleviated by immediate removal/lifting up of tumor by the
surgeon after sternotomy. Cardiopulmonary bypass is often on standby,
either as a rescue measure or to facilitate resection. In patients with
critical positional symptoms of cardiopulmonary compression, induction
of anaesthesia with maintenance of spontaneous ventilation may still be
unsafe. Alternatives such as extracorporeal membrane oxygenation may
need to be established prior to surgical resection 7, 8.
In our patient’s case, mass effect on the cardiorespiratory system was
somewhat mitigated after drainage of pericardial effusion. There was
only a mild compression of distal trachea and we had the knowledge that
she was previously uneventfully intubated during neonatal resuscitation.
In our patient’s case, tumor resection occurred > 34 weeks
gestational age and weight > 2000 grams to allow for
cardiopulmonary bypass rescue or ECMO 9, 10, which may
be precluded in smaller patients.
Intraoperatively, hemodynamic disturbances should be anticipated with
tumor manipulation and surgical blood loss. Adequate IV access is
essential as hemodynamic instability is expected and significant blood
loss, while rare, can occur. In our patient, an infusion of dopamine and
liberal fluid resuscitation including blood products were required to
maintain hemodynamic stability. In addition, epinephrine and vasopressin
infusions were immediately available. Despite these precautions,
permissive hypotension was still required to facilitate surgical
resection.
Postoperatively, most patients experience smooth recovery. Our patient
was uneventfully discharged on POD 4. Histological examination showed a
predominately mature teratoma with immature components, with elements
from all three primitive germ cell layers. Patient returned on POD 36
for a repeat cardiac MRI, which showed no residual tumor.