Complications with massive sacrococcygeal tumor resection on a premature neonate

Abstract

Resection of large sacrococcygeal teratomas (SCT) in neonates can pose many anesthetic challenges. The pathophysiology of the SCT determines the varying management. We present a case report of a 34-week newborn with a massive Altman type 3 SCT. The surgery was delayed 2 days because of hyperkalemia; however, as a result of continued tumor lysis the patient's condition had worsened with little improvement of the potassium level. During the surgery, the patient had issues of bleeding needing massive transfusion. Ventilation was also difficult at times because of the massive tumor resting on the chest, resulting in respiratory acidosis. We also had difficulty in maintaining the temperature. This patient did well after the surgery and was discharged home. We address here the anesthetic issues involved in the perioperative care management of a premature infant with a massive SCT.

Cardiac arrest during excision of a huge sacrococcygeal teratoma - A report of two cases -

“…Although the mortality rate for newborns with SCT is at most 5%, the mortality rate for fetal SCT exceeds 50%, and fetal SCT associated with non-immune hydrops is uniformly fatal [3]. Predictors of poor outcome include diagnosis before 20 weeks gestation, delivery before 30 weeks, low birth weight, Apgar score less than 7, malignant histotypes, polyhydramnios, placentomegaly and development of hydrops [2]. …”

“…Abraham et al [2] has been reported that the manual ventilation and lifting the tumor by surgeon can help with the ventilation. And it is very difficult to maintain body temperature because of the large surface area of the SCT compared to the patient.…”

“…And it is very difficult to maintain body temperature because of the large surface area of the SCT compared to the patient. Hypothermia could worsen coagulopathy, and prolong the effect of the anesthetics [2]. In order to maintain body temperature, thermoneutral incubator, force warming device, and intravenous fluid warmer should be used.…”

“…SCTs are the most common congenital neoplasms, occurring in 1 of 40,000 infants, with a female predominance of 95% [2]. Large SCTs are associated with significant perinatal morbidity and mortality (5-50%) [3].…”

Preemptive Delivery and Immediate Resection for Fetuses with High-Risk Sacrococcygeal Teratomas

“…Delaying surgery with the intention of stabilizing the infant in the NICU can lead to worsening hemodynamic status due to persistent shunt physiology or in some cases intratumoral hemorrhage or tumor rupture. Blood loss and massive transfusion requirements can lead to disseminated intravascular coagulation, and transfusion of factor VIIa has been recommended in such cases [25]. Although we recommend complete resection with coccygectomy after the infant has stabilized and grown [21,25,26], it is interesting that early debulking of SCTs has been shown in some cases to result in the disappearance of malignant elements [27].…”