2017 FSA Posters

P017: ANESTHETIC MANAGEMENT OF CAROTID BODY TUMOR EXCISION IN AN 8 YEAR OLD PATIENT
David S Haverman, MD, MPH, Benjamin Pruden, MD, Eliane Varga, MD; Jackson Memorial Hospital

Introduction: This case report will describe the anesthetic management of an 8 year-old girl with a carotid body paraganglioma.  Carotid body tumors are rare tumors of extra-adrenal chromaffin cells most commonly due to mutations in the succinate dehydrogenase (SDH) genes.  They are classified according to the Shamblin scale based on how they related to the carotid arteries.  The scale goes from I (little attachment to carotid vessels) to III (complete surrounding of carotid vessels).   Carotid body tumors (CBT) may be functionally similar to pheocromocytoma and testing for urinary catecholamine levels is often indicated.

Methods: BA is an 8 year-old girl with no past medical history who presented with an asymptomatic right neck mass.  Mom reported that the mass had been slowly growing over the previous 18 months.  She was developmentally appropriate, up to date on her immunizations, and lived at home with mom and dad.  Urinary VMA testing was negative and it was concluded that the tumor was non-functional.  She underwent embolization of the mass in the interventional radiology suite 3 days prior to operative excision.  She tolerated the initial procedure well with no surgical or anesthetic complications

Results: The decision was made to proceed with the operation with arterial line catheterization, central access via the femoral vein, SSEP monitoring, hypoglossal EMG monitoring, and cerebral oximetry monitoring in addition to the ASA standard monitors.   The patient was induced via IV propofol and was intubated without complication using a MAC 2 blade and a 6.0 cuffed ETT.  The tube was secured in place and two additional peripheral IVs were placed.  An arterial line was placed in the R radial artery.  A central line was not placed per the request of the surgeon due to anticipation of minimal blood loss.  Neurophysiologic monitors were placed as were cerebral oximetry monitors.   Anesthesia was maintained with infusions of propofol and remifentanil with minimal sevoflurane.   The mass was discovered to be Shamblin 3 on dissection and during excision the common carotid artery was injured.  Proximal control was obtained and there was return to baseline of neuro monitoring.  The decision was made to ligate the common carotid artery and the mass was removed.  Prior to extubation, the patient was noted to be moving all four extremities and equal grimace on the bilateral face was observed.  The patient was transferred to the PICU post-operatively.

Discussion: CBT removal requires complex anesthetic management necessitating invasive access and monitoring.  Arterial cannulation and cerebral monitoring are essential to facilitate maintenance of cerebral perfusion pressure and hemodynamic stability against sudden hemodynamic changes.  Central access should be obtained for Shamblin class 2 or 3 tumors with a high risk of vascular injury.  Good communication amongst a multidisciplinary team of surgeons and anesthesiologists is extremely important as well.  If a tumor is Shamblin class 3, a vascular surgeon should be available for the possibility of carotid artery injury.