Beyond the OR - challenges of MRI anesthesia in a complex oncologic patient: a case report.

backgroundAnesthesia consultation for oncologic patients who require diagnostic imaging may be necessary due to anxiety, claustrophobia, and inability to lie flat secondary to pain, physical limitations, or cardiopulmonary comorbidities. This case report highlights a patient with complex pulmonary comorbidities who successfully underwent Magnetic Resonance Imaging (MRI) with comprehensive planning directed by the anesthesia team with the use of atypical positioning strategies and a flexible MRI coil. CASE PRESENTATION: A 54-year-old man presented with metastatic lung adenocarcinoma complicated by phrenic nerve dysfunction and hemidiaphragmatic paresis, chronic obstructive pulmonary disease (COPD), and recurrent radiation recall pneumonitis (RRP). He also reported recent worsening orthopnea, dyspnea, and persistent cough requiring a steroid taper and daily inhaler treatments. Pulmonary function tests demonstrated severe obstruction, moderate restriction, and poor diffusion capacity. In addition, the patient reported utilizing continuous positive airway pressure (CPAP) at night for symptom relief stemming from hemidiaphragmatic paresis. Given these findings, anesthesia consultation was requested to facilitate the brain MRI, which requires supine, fully recumbent positioning. Due to the patient’s compromised pulmonary status and worsening clinical picture, he was deemed high risk for anesthetic management. After careful consideration, the case proceeded with monitored anesthesia care (MAC), with available resources to escalate anesthetic care if necessary. Initially, trials of ventilator-assisted CPAP in a semi-recumbent position failed due to patient-reported dyspnea and increased work of breathing. Eventually, lateral decubitus positioning was better tolerated and only required oxygen delivery through a simple facemask. However, the standard MRI brain coil was not suitable in this position, thus an alternative “flex” coil was adapted without significantly compromising image quality. Ultimately, this combination of strategies was successful, while avoiding the need for additional pharmacological agents or advanced hemodynamic and airway support.

conclusionsThis case illustrates the need for innovative, multidisciplinary strategies in non-operating room anesthesia (NORA) settings, which often carry a higher risk of anesthetic complications. In our case, avoiding sedatives and general anesthesia, while adapting patient positioning and equipment, enabled safe and effective imaging conditions. This approach highlights how individualized planning, comprehensive anesthetic considerations, and interprofessional collaboration can overcome significant clinical barriers.