Introduction: Anterior mediastinal masses in pediatric patients represent a significant anesthetic challenge due to the high risk of respiratory and cardiovascular collapse, particularly during anesthetic induction and major thoracic procedures. Available evidence is limited and is based mainly on case reports, highlighting the importance of documenting clinical experiences that contribute to the understanding and management of these conditions. Case Presentation: We present the case of an 11-year-old female patient diagnosed with a large anterior mediastinal mass occupying the left hemithorax, with extension to the pulmonary vessels, associated with respiratory failure and recurrent pleural effusions. She underwent anterior sternotomy, left upper lobectomy, and tumor resection under balanced general anesthesia. The intraoperative period was complicated by massive hemorrhage, requiring activation of the massive transfusion protocol, advanced hemodynamic support, and prolonged invasive mechanical ventilation. In the immediate postoperative period, she developed severe hypoxemia and was admitted to the Pediatric Intensive Care Unit. Intervention and Results: Anesthetic management was performed using balanced general anesthesia, preserving spontaneous ventilation during induction and delaying neuromuscular blockade until the start of surgery. Management included invasive monitoring, vasopressor support, lung-protective ventilation strategies, and activation of the massive transfusion protocol. The patient developed postoperative respiratory failure requiring admission to the Intensive Care Unit. No complications attributable to the anesthetic technique were documented. Conclusion: This case highlights the need for an individualized and dynamic anesthetic approach in pediatric patients with mediastinal masses. It also underscores the additional challenges posed by emergency scenarios, in which a complete preoperative evaluation and access to advanced resources recommended in the literature are not always feasible. In this context, decision-making based on pathophysiology, adaptation to available resources, and multidisciplinary coordination are essential to optimize perioperative outcomes in high-risk patients.
Huertas et al. (Tue,) studied this question.