Awake cardiopulmonary bypass under neuraxial anaesthesia for elective posterior mediastinal mass excision

A pre-existing compression of the airways and/or great vessels secondary to a large mediastinal mass, risks respiratory and haemodynamic compromise in which complete airway obstruction and cardiovascular collapse are anticipated. Most of the literature routinely recommends having cardiopulmonary bypass (CPB) on stand-by with the perfusionists on ready mode and machine primed. Establishment of awake CPB for mediastinal tumour resection has been scarcely reported, with most being done under local anaesthesia (LA). We report a case of 65-year-old woman with a large, asymptomatic, right posterior mediastinal tumour scheduled for elective surgical excision in our centre. The surgery in the previous hospital, which had no CPB service, was postponed after the patient experienced haemodynamic and ventilatory events. In view of the events, we opted for early initiation of CPB prior to general anaesthesia to avoid delays in activating stand-by CPB. The cardiothoracic surgical team specifically wanted a smooth femoro-femoral cannulation, hence neuraxial anaesthesia was performed. This unconventional approach of awake CPB under neuraxial block provides a favourable cannulation site compared to a field infiltrated with LA, anaesthesia maintenance if cannulation is required contralaterally, and predictable analgesia for the awake patient throughout the procedure.