What is the recommended anaesthetic management for a patient with an ectopic parathyroid adenoma in the mediastinum and End-Stage Renal Disease (ESRD) undergoing Video-Assisted Thoracic Surgery (VATS)?

From the Guidelines

The recommended anaesthetic management for a patient with an ectopic parathyroid adenoma in the mediastinum and End-Stage Renal Disease (ESRD) undergoing Video-Assisted Thoracic Surgery (VATS) should prioritize a balanced approach, focusing on hemodynamic stability, and incorporating regional analgesic techniques, such as paravertebral block or ESP block, to minimize opioid use and optimize postoperative pain management. When considering the anaesthetic management for such a patient, it's crucial to start with a thorough preoperative assessment, including evaluation of calcium levels, electrolytes, and renal function, given the complexities of ESRD and the potential for electrolyte imbalances due to hyperparathyroidism 1.

Key Considerations:

• Induction of anaesthesia can be achieved with propofol and fentanyl or remifentanil infusion, taking into account the patient's renal status and potential for altered drug pharmacokinetics.
• Muscle relaxation can be facilitated with rocuronium, which does not rely on renal excretion, making it a safer choice in patients with ESRD.
• Maintenance of anaesthesia should utilize sevoflurane or desflurane with titrated opioids, considering the need to balance analgesia with the potential for respiratory depression, especially in a patient with ESRD who may have altered drug clearance.
• One-lung ventilation is necessary and can be achieved with a double-lumen endotracheal tube or bronchial blocker, requiring careful consideration of lung isolation techniques to ensure adequate ventilation and oxygenation.
• Fluid management should be restrictive, with careful monitoring of electrolytes, especially calcium, potassium, and magnesium, to prevent complications related to fluid overload or electrolyte imbalances.
• Invasive monitoring, including an arterial line, is recommended, with central venous access considered if significant fluid shifts are anticipated, to closely monitor the patient's hemodynamic status.
• Postoperative care should include monitoring for hypocalcemia, which may occur after adenoma removal, and managing pain with a multimodal approach that includes regional techniques and non-opioid analgesics to minimize opioid-related side effects.

Pain Management:

• Regional analgesic techniques, such as paravertebral block or ESP block, are strongly recommended as part of a multimodal analgesia strategy for patients undergoing VATS, as they have been shown to be effective in reducing postoperative pain and opioid consumption 1.
• The choice between paravertebral block and ESP block may depend on the specific surgical approach and patient factors, with ESP block potentially offering an alternative when paravertebral block is not feasible.
• Other regional techniques, like serratus anterior plane block, may also be considered, although their efficacy compared to paravertebral and ESP blocks needs further evaluation.
• The use of opioid-sparing strategies is crucial in patients with ESRD undergoing VATS, given the potential for altered opioid pharmacokinetics and increased risk of opioid-related side effects.

From the Research

Anaesthetic Management for Ectopic Parathyroid Adenoma in Mediastinum with ESRD Undergoing VATS

The anaesthetic management for a patient with an ectopic parathyroid adenoma in the mediastinum and End-Stage Renal Disease (ESRD) undergoing Video-Assisted Thoracic Surgery (VATS) involves several key considerations:

• Preoperative evaluation and optimization of the patient's renal function and electrolyte balance are crucial 2, 3.
• The use of minimally invasive techniques such as VATS is recommended due to its benefits of early postoperative recovery and less complications 2, 4, 5, 3.
• Intraoperative monitoring and management of the patient's vital signs, including blood pressure, heart rate, and oxygen saturation, are essential 4, 3.
• The anaesthetic technique should be tailored to the individual patient's needs, taking into account their renal disease and potential electrolyte imbalances 6.
• A multidisciplinary approach, including input from anaesthesiologists, surgeons, and nephrologists, is necessary to ensure optimal patient care 3.

Key Considerations for Anaesthetic Management

• Preoperative optimization: Optimization of the patient's renal function and electrolyte balance before surgery is crucial to reduce the risk of complications 2, 3.
• Minimally invasive technique: The use of VATS is recommended due to its benefits of early postoperative recovery and less complications 2, 4, 5, 3.
• Intraoperative monitoring: Close monitoring of the patient's vital signs and electrolyte balance during surgery is essential to prevent complications 4, 3.
• Multidisciplinary approach: A team-based approach, including input from anaesthesiologists, surgeons, and nephrologists, is necessary to ensure optimal patient care 3.

Potential Complications and Challenges

• Electrolyte imbalances: Patients with ESRD are at risk of electrolyte imbalances, which can be exacerbated by surgery and anaesthesia 6.
• Renal dysfunction: The patient's renal disease may be affected by the surgery and anaesthesia, and close monitoring of renal function is necessary 2, 3.
• Respiratory complications: Patients undergoing VATS may be at risk of respiratory complications, such as pneumothorax or respiratory failure 4, 3.