TITLE:
Anesthetic Management of Nasopharyngeal Angiofibroma Resection with Carotid Invasion in a Pediatric Patient
AUTHORS:
Julia Reich Camasmie, Michele Cristianini, Rafael Moura, Claudia Biasi, Carlos Darcy Bersot
KEYWORDS:
Nasopharyngeal Angiofibroma, Anesthetic Management, Hemodynamic Instability
JOURNAL NAME:
Open Access Library Journal,
Vol.3 No.8,
August
12,
2016
ABSTRACT:
The nasopharyngeal angiofibroma is an aggressive, vascular tumor that may
represent a challenge for the anesthesiologist by the risk of profuse bleeding.
We report the case of a 13 years old, 52 kg, ASA1, who was scheduled for the
resection of an angiofibroma invading facial sinuses and internal carotid
artery, and submitted to external carotid and internal maxillary arteries
embolization one day before surgery. Mallampati 2, previous successful
intubation reported. Induction was made with propofol, fentanyl, lidocaine and
rocuronium, followed by intubation by direct laringoscopy. Sevoflurane and
remifentanyl were used for maintenance. Central venous access and arterial
catheterization were provided. Inicial arterial gasometry was normal. During
tumor resection close to the ethmoidal cells, there was profuse bleeding that required
intensive volemic resuscitation and hemotransfusion. The cavernous part of the
angiofibroma was resected by a neurosurgery team. During the whole procedure,
the patient received 3500 ml of Saline Solution 0.9%, 4000 ml of RL, 1000 ml of
hydroxyethyl starch, four RBC units, two plasma units and 4 platelets units.
Serial arterial blood gas analysis revealed Hb = 6 g/dL as the minor value of
hemoglobin and pH was physiological all the time. Fenylephrine, adrenaline and
noradrenaline were infused. Even after the massive volume restitution,
responsiveness to hydration was verified by the delta pulse pressure curve.
Total diuresis was 300 ml. The total duration of the procedure was 9 hours. The
patient was sent to the ICU after a tracheostomy. Transthoracic US revealed
collapsed cava vein leading to new volume resuscitation.