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.