Current anesthesiological approach to mediastinal surgery
Mediastinal anesthesia for diagnostic or therapeutic procedures can present more risks during the induction phase due to potential respiratory or cardiovascular collapse for direct compression by the mediastinal mass. The anesthesiologist must assess some preoperative features of patients (including patients symptoms) before initiating the procedure and categorized them into risk groups. Awake induction under local anesthesia and spontaneous breathing can be mandatory in high risk patients. Management of the airway in these patients can be a real challenge, thus different airway intubation strategies must be kept in mind before initiating the induction of anesthesia including selective endobronchial tubes under fiberoptic guidance, rigid bronchoscope jet ventilation and tracheal stenting. Cardiopulmonary by-pass might be needed if predicted great vessels invasion or if cardiovascular or respiratory collapse appears. Although non-intubated procedures are becoming more frequent for pulmonary surgical procedures, there is still a lack of evidence of its advantages and disadvantages in mediastinal surgery, so special care must be taken before embarking in this novel approach. Most severe complications after miastenia gravis surgery appear in terms of postoperative myasthenic crisis, that should first be predicted by the anesthesiologist during preoperative assessment. Short and middle action neuromuscular blocking agents can be safely used in reduced dosis, and sugammadex seems to reverse effectively and safely their action in a very short time.