Analgosedation With Dexmedetomidine in a Patient With Superior Vena Cava Syndrome in Neurosurgery

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To JNA Readers:
Intraoperative management of patients with superior vena cava (SVC) syndrome can present significant challenges for the Anesthesiologist. Such patients usually undergo only urgent surgery, and the major concerns are the possibility of complete airway obstruction and diminished venous return to the heart resulting in cardiovascular collapse.1
We describe successful anesthetic management with dexmedetomidine combined with local anesthesia and a scalp block for a patient with SVC syndrome during a neurosurgical procedure for dura mater reconstruction. The patient, aged 48, ASA classification IV (American Society of Anesthesiologists),2 with disseminated malignant disease had surgery for brain metastasis (January 2016). Previously, a radical mastectomy of the right breast had been performed (2012). At this time, the patient had metastases in the lungs, liver and left adrenal gland, and mediastinal lymph nodes. One month after her neurosurgical procedure, she was again admitted to the hospital (February 2016), with the diagnosis of SVC syndrome. The patient had distended veins on the front of the chest wall, and an edematous neck, right arm, and face. She was dyspnoic and would not tolerate a lying position. Simultaneously, a pseudomeningocele developed in the location of the previous neurosurgery, and further surgery was required to perform reconstruction of the dura. At the time, a computed tomographic scan of the thorax showed a thrombosis at the confluence of the right and left brachiocephalic veins due to a tumorous infiltration, and thrombosis of both subclavian veins and the right internal jugular vein. Tumorous masses in the superior lobe of the left lung had infiltrated the mediastinum to the aortic arch, left arteria pulmonalis, and the lobar bronchi for the superior lobe of the left lung (Fig. 1). Because of the high risk involved in general anesthesia, procedural sedation with dexmedetomidine was performed, together with a scalp block, standard monitoring, and bispectral index. Dexmedetomidine was administered in a dose of 1 mcg/kg/h with bispectral index values between 70 and 80. A scalp block was performed with a mixture of 0.5% levobupivacaine and 2% lidocaine. During surgery, the patient was breathing spontaneously with a nasal oxygen catheter supplementation of 5 L/min and SpO2 100%. After the procedure, the patient was transferred to the intensive care unit hemodynamically stable and awake.
We believe this ASA class IV patient with SVC syndrome was successfully managed by administering analgosedation with dexmedetomidine together with scalp block, therefore, avoiding potential complications from general anesthesia.

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