Anesthetic management of thoracotomy for massive intrathoracic solitary fibrous tumor of the pleura: a case report

A 76-year-old woman (62 kg; 164 cm) presented with worsening dyspnea on exertion and moderate asthma. These symptoms began one month before she was admitted to the thoracic surgery department. The chest contrast-enhanced computed tomography (CT) revealed that a large pleural-based mass (craniocaudal diameter of 15.3 cm) with uneven density, vague margin, and inhomogeneous enhancement occupied most of the left hemithorax (Fig. 1A). This space-occupying lesion was medially abutting the left pulmonary artery, ascending aorta, descending aorta, left pericardium, and left ventricle, resulting in the collapse of the left pulmonary vasculature, bronchial obstruction, and lower lobe atelectasis (Fig. 1B), the right shift of mediastinum, pericardium invasion, and left ventricle compression (Fig. 1A). We did not detect abnormalities in multiple laboratory tests except for a slight neutrophil increase. Then, we performed a CT-guided percutaneous transthoracic needle biopsy two days after, which conferred the SFTP diagnosis. Additionally, considering that a huge tumor can considerably affect cardiac structure and coronary artery, we conducted echocardiography, coronary CT angiography (CCTA), and dynamic electrocardiogram to eliminate severe heart diseases such as coronary artery stenosis ventricular arrhythmia. After a comprehensive preoperative evaluation and multidisciplinary discussion, we decided to remove the tumor through thoracotomy.

In the operation room, we applied standard monitoring, including non-invasive blood pressure, electrocardiogram, pulse oximeter, and bispectral index. We established invasive blood pressure monitoring in the right radial artery and inserted the central venous catheter through the right internal jugular vein under ultrasound guidance for intravenous infusion and central venous pressure monitoring. Given the underlying hazard of intraoperative circulatory disturbance, especially cardiac herniation after pericardiectomy, emergency resuscitative strategies, including autologous blood transfusion and cardiopulmonary bypass, were put on standby.

The anesthesia induction was performed in the supine position. First, dexmedetomidine (0.5 µg/mg) was intravenously pumped for 10 min. We ensured that the patient had no dyspnea and precipitous hemodynamic fluctuation under sedation. Next, etomidate 0.3 mg/kg, sufentanil 0.5 µg/kg, and cisatracurium 0.15 mg/kg were intravenously infused successively. Visual laryngoscope-guided double-lumen endobronchial intubation and fiberoptic bronchoscope were used to ensure the proper location of the double-lumen tube in the right main bronchus. We successfully inserted the Robertshaw 32 F catheter at 28 cm from the incisor. We conducted lung auscultation to reconfirm the successful ventilation after lung isolation. The respiratory parameters were adjusted during the operation to maintain end-tidal carbon dioxide partial pressure at 35 to 45 mmHg. Regarding anesthesia maintenance, the target blood concentration of remifentanil was 1 ng/mL. Propofol infusion was given with a target-controlled infusion (TCI) system, and the initial target blood concentration was set at 3.0 µg/mL with adjustments of 1.5–1.7 µg/mL to achieve the expected sedation level by monitoring the BIS value from 45 to 60. The inhalation concentration of sevoflurane was maintained at 1%. The Marsh parameter model was referenced, and the ideal concentrations of propofol and remifentanil were set at 10 mg/mL and 20 µg/mL, respectively. Besides, cisatracurium was intravenously pumped based on the train-of-four (TOF) stimulation value. We used a heated transfusion and insulation blanket to ensure the stability of the patient’s temperature during the surgery.

The surgery was performed in the right lateral position. We removed the whole tumor, the left upper lobe, and part of the pericardium that adhered to the tumor, as well as a portion of the phrenic nerve fused in the tumor and the pericardium. To improve postoperative respiratory function, we conducted diaphragmatic plication after tumor resection. After the resection, we properly performed sputum aspiration and lung inflation to avoid any pulmonary hemorrhage or air leakage. However, when the surgeon used a vacuum extractor to attract the drainage tube placed outside the pericardium after suturing the chest wall incision, the blood pressure sharply dropped to 40/20 mmHg. Meanwhile, the heart rate went up to 180 beats/min and rapidly decreased to 50 beats/min. The anesthesiologist immediately stopped the surgeon from conducting the negative pressure suction. Then, the blood pressure and heart rate swiftly returned to normal.

The blood loss was approximately 300 ml. The blood pressure, heart rate, and oxygen saturation were normal before leaving the operating room. The patient was sent to the intensive care unit (ICU) for postoperative observation and extubated on the first postoperative day. No evidence of residual disease was detected in the postoperative CT. On the seventh postoperative day, the patient was discharged without any complications.