Perioperative Management of One-Lung Ventilation in an Adolescent With Metastatic Osteosarcoma Complicated by Bilateral Pneumothoraces

Thoracic anesthesia in pediatric patients is challenging due to anatomical and physiological factors that increase susceptibility to hypoxemia during one-lung ventilation (OLV). These complexities are further magnified in children with underlying oncological disease and poor pulmonary reserve. We report anesthetic management of a 16-year-old, 32 kg boy with metastatic osteosarcoma presenting with recurrent bilateral pneumothoraces scheduled for right video-assisted thoracoscopic surgery (VATS) and pleurodesis. The coexistence of bilateral pneumothoraces with compromised pulmonary reserve, with a potential risk of tension pneumothorax, posed significant anesthetic challenges, particularly for OLV. We describe perioperative considerations, anesthetic technique, and strategies to maintain oxygenation and hemodynamic stability. This case highlights the importance of careful planning, lung-protective ventilation, and multidisciplinary coordination in managing pediatric thoracic cases. Anesthetic management included standard American Society of Anesthesiologists (ASA) monitoring with invasive arterial pressure, induction with remifentanil, propofol, and rocuronium, and placement of a left-sided double-lumen tube, confirmed with fiberoptic bronchoscopy. A lung-protective strategy was applied with low tidal volumes, titration of fraction of inspired oxygen (FiO₂), stepwise positive end-expiratory pressure (PEEP) adjustments, and tolerance of permissive hypercapnia. Due to the risk of desaturation, intraoperative SpO₂ was maintained between 92% and 95% through FiO₂ adjustments, recruitment maneuvers, and judicious hemodynamic support with ephedrine. Postoperatively, after confirming successful reinflation of the right lung, the patient was successfully extubated, managed with multimodal intravenous analgesia, and had a stable recovery by day three. This case underscores the importance of meticulous anesthetic planning, vigilant intraoperative management, and multimodal analgesia in pediatric oncology patients undergoing thoracic surgery. Tailored strategies for OLV in children with bilateral pneumothoraces and metastatic disease are critical to ensure safe outcomes.