305

TUMOR MEDIASTINUM
 Identitas
Nama : Tn. YS
Usia : 22 th
No. RM : 178xxxx
Berat badan : 58 kg
Diagnosis : Tumor mediastinum + VCSS
grade 0
Rencana Tindakan : Open Lung Biopsy
 Anamnesa
• Pasien mengeluhkan batuk sejak 4 tahun yang lalu,
tidak berhenti walaupun sudah berobat, 1 tahun terakhir
batuk darah yang hilang timbul, batuk tidak disertai
sesak nafas.
• Riwayat pengobatan TB paru sebelumnya (-). Riwayat
demam (-). Riwayat penurunan berat badan (+) 2 kg
dalam 2 bulan terakhir.Riwayat benjolan pada bagian
tubuh lain (-).
• Riwayat tumor mediastinum sejak 3bulan, diketahui
sejak September 2019, belum pernah dilakukan operasi
(-), riwayat FNAB 1x namun tidak berhasil pada bulan
oktober 2019.
 Pemeriksaan Fisik
• Kesadaran : compos mentis
–Tensi : 121/83 mmHg
– Nadi : 72 x/m
–Respirasi : 20 x/m
–SpO2 : 97 % udara bebas
• Kepala : Malampati II, Buka mulut >3 jari
• Leher : ROM baik
• Thorax : Jantung  murmur (-), gallop (-)
Paru → VBS kanan menurun mulai ICS III
Ronkhi -/-, wheezing -/-
• Pemeriksaan lain dalam batas normal
 Pemeriksaan Penunjang
• Laboratorium (7/10/19)
Hb Ht Leuko Trom PT aPTT INR
14,8 43,6 7.420 170.000 15,1 1,07 30,6

Ur Cr SGOT SGPT Na K GDS

23 1,03 18 31 143 3,7 147

• EKG : Sinus ritme

• TFP : Normal
Chest X-Ray
 foto thorak

• kesan masih terlihat opasitas inhomogen

kanan tengah daerah perihiler yang
tampaknya mengecil, curiga inflammatory
lesion dd/ neoplasia?
CT scan
 CT Scan
• Tampak massa solid inhomogen batas
tegas, dengan kalsifikasi kecil multiple di
dalamnya, tepi relatif reguler, berukuran
5,5 cm x 6 cm x6 cm, pada mediastinum
anterior superior kanan.
• Massa tampak menempel pada aorta
ascenden dan sebagian arcus aorta -->
sugestif suatu germ cell tumor (pulmonary
teratoma)
 Assesment
• Tumor mediastinum
• ASA II

• Planning : General anesthesia

 Permasalahan
• Massa mediastinum  tanda dan gejala
Superior Vena Cava Syndrome
Yu’s classification (clinical)

1. Grade 0: asymptomatic (imaging evidence of SVC obstruction)

2. Grade 1: mild (plethora, cyanosis, head and neck edema)

3. Grade 2: moderate (grade 1 evidence + functional impairment)

4. Grade 3: severe (mild/moderate cerebral or laryngeal edema,

limited cardiac reserve)

5. Grade 4: life-threatening (significant cerebral or laryngeal edema,

cardiac failure)

6. Grade 5: fatal
Superior Bull neck

Vena
Cava Kolateral vena

Syndrome

Wajah Bengkak

Ekstremitas atas
oedem dan
hiperemis
 Right Heart &
Tracheobronchia Pulmonary
SVCS
l Compression
Sulit Bernafas Obstruksi
drainase vena Gagal jantung
Suara nafas di ekst atas kanan
tambahan
Edema wajah
Batuk dan Syncope
ekstremitas during valsava
Dada yg tidak atas
nyaman, Aritmia
diperberat Sulit menelan
apabila posisi
supine Vena leher dan Distension
dada distensi vena jugularis

Difficult airway Paresis pita Penurunan

or intubation suara reserve paru
 Prinsip umum anestesi pada pasien
dengan VCSS
• Akses vena dari ekstremitas bawah
• Hindari infus iv di ekstremitas atas
• Manipulasi jalan napas harus gentle
• Penggunaan steroid atau diuretik
intraoperative dapat berguna
• Hindari batuk, tegang
• Posisi supine dihindari
 Preoperatif
• Puasa 6 jam preoperasi
• Pasang IV line, maintenance cairan
dengan kristaloid 110 cc/jam
• Sedia darah
• Alat/obat disiapkan : ETT, stylet/mandrain, obat-obat
emergency
• Monitor : NIBP, SpO2, ECG
• Komunikasikan prosedur dengan pasien
 Intraoperatif
• Induksi dengan fentanyl 2 mcg/kgBB, propofol 2
mg/kgBB. Jika jalan nafas dapat dikuasai,
diberikan atracurium 0,5 mg/kgBB

• Maintenance 
– O2, N20, isofluran, fentanyl, atracurium

• Monitoring 
– BP, EKG, SaO2, Urine Output
 Postoperatif
• Post op ruangan ICU
• Analgetik  morfin 10 mcg/kg/jam +
Paracetamol 4x1 gram IV
 What is One Lung Ventilation (OLV)?

• It is the intentional collapse of a lung on

the operative side of the patient which
facilitates most thoracic procedures.
• Requires much skill of the anesthesia team
– Difficult to place lung isolation equipment
– Ability to overcome hypoxic pulmonary
vasoconstriction
– Patient population is comparably “sicker”
 Definition of Terms
• Dependent Lung or Down Lung
– The lung that is ventilated
• Non-dependent Lung or Up Lung
– The lung that is collapsed to facilitate the
surgery
 Methods of Lung Separation
• Bronchial blockers
– Single-lumen tracheal tubes w/ a bronchial blocker (Univent)
– Arterial embolectomy catheter (ie Fogarty)
• Single-lumen endobronchial tubes
– Gordon-Green tube (carinal hook)
• Double-lumen endobronchial tubes
– Robert-Shaw (R or L), Carlens (R), White (L)
– Carlens and White both have carinal hooks
– From 35Fr to 41Fr (35, 37, 39, 41)
– 26Fr smallest size
• Used for children as young as 8 years
– 28Fr and 32Fr used for pediatric patients 10 and older
Double Lumen Tubes
 Indications for One-Lung
Ventilation
• Absolute
– Isolation of one lung from another to prevent
spillage or contamination (infection, massive
hemorrhage)
– Control of distribution of ventilation
• Bronchopleural fistula
• Surgical opening of major conducting airway
– Unilateral bronchopulmonary lavage
 Indications for One-Lung
Ventilation
 Relative
 Surgical exposure- high priority
 Thoracic aortic aneurysm
 Pneumonectomy
 Upper lobectomy
 Surgical exposure- lower priority
 Middle lobe lobectomies
 Esophageal resection
 Thoracoscopy
 Thoracic spine procedures
 Post-removal of totally-occluding chronic unilateral
pulmonary emboli
Double Lumen Endobronchial
Tubes
Double Lumen Endobronchial
Tubes
 Advantages
 Relatively easy to place
 Allow conversion back and forth from OLV to
two-lung ventilation
 Allow suctioning of both lungs individually
 Allow CPAP to be applied to the non-dependent
lung
 Allow PEEP to be applied to the dependent lung
 Ability to ventilate around scope in the tube
 Disadvantages
• Cannot take patient to PACU or the Unit
• Must be changed out for a regular ETT if
post-op ventilation
• Correct positioning is dependent on
appropriate size for height of patient
– Length of trachea
Terima Kasih