Propofol and remifentanil total intravenous anesthesia and the preservation of spontaneous respiration for a patient with mediastinal mass

provided the original work is properly cited. CC A large mediastinal mass directly compressing the pulmonary arteries and the tracheobronchial trees may be associated with severe ventilation-perfusion (V/Q) mismatch. There have been some reports in the literature of sudden collapse involving mediastinal masses, possibly caused by the mass impinging on the pulmonary artery and the contralateral bronchus, causing hypoxemia and fatal V/Q mismatch while administrating general anesthesia [1]. In formulating an anesthetic plan for these patients, anesthesiologists should consider which anesthesia method will be least harmful on a case-by-case basis. This “NPIC” (noli pontes ignii consumere) anesthetic induction may be titrated infusion of intravenous anesthetics, preserving spontaneous respiration until the airway is definitively procured [2]. Herein, we report a case of anesthetic management during surgery to excise a mediastinal mass causing severe V/Q mismatch, in which total intravenous anesthesia (TIVA) without muscle relaxant, and the preservation of spontaneous respiration, were successfully used. A 60-year-old woman was admitted to our hospital for dyspnea that had developed 1 year ago. A computed tomography scan of the chest revealed a large middle mediastinal tumor compressing the right pulmonary artery, left main bronchus, distal trachea and left atrium (Fig. 1). On arrival at the operating room, the patient had an initial SpO2 of 89% in the supine position. Sedation was induced with an initial effect-site concentration of 1.5 μg/ml of propofol and 0.5 ng/ml of remifentanil. A fiber optic bronchoscope loaded with a 37 French double lumen endobronchial tube (DLT) was introduced into the trachea. We could not advance the bronchoscope into the left main bronchus owing to severe narrowing of distal trachea and the left main bronchus. Therefore, we decided to place the endobronchial portion of the DLT at the right main bronchus. Following fiber optic intubation while the patient was conscious, propofol and remifentanil were gradually increased to effect-site concentrations of 2-3 μg/ml and 1-1.5 ng/ml, respectively. The patient