Authors: Kalshan R et al.
Cureus, Volume 18, Issue 1, Article e101824, January 2026. DOI: 10.7759/cureus.101824.
Summary
This case report describes the anaesthetic management of a 47-year-old woman undergoing cytoreductive surgery for a giant ovarian tumour associated with an extraordinary 28 litres of ascitic fluid. The patient presented with severe abdominal distension, poor functional capacity (METs < 3.5), obesity, and symptoms of respiratory compromise, all of which significantly increased perioperative risk. Key concerns included airway and ventilatory management under high intra-abdominal pressure, haemodynamic instability from massive fluid shifts, and the potential for cardiovascular collapse during tumour decompression.
The anaesthetic plan combined general anaesthesia with epidural analgesia, allowing attenuation of the stress response, reduced systemic opioid requirements, and improved postoperative pain control. Pre-induction epidural placement was performed in the sitting position, followed by induction and intubation in the ramped position to optimise airway alignment and oxygenation. Lung-protective ventilation strategies were used, with careful attention to airway pressures, which decreased markedly as ascitic fluid was gradually drained.
Ascitic fluid was drained slowly to avoid abrupt haemodynamic deterioration and re-expansion pulmonary oedema. Invasive arterial pressure monitoring, serial blood gas analysis, and judicious fluid and blood product replacement were used to preserve end-organ perfusion. Colloid and albumin were administered to maintain oncotic pressure in the setting of massive third-space losses. Active warming strategies were employed throughout the prolonged procedure to prevent hypothermia.
Postoperatively, the patient required short-term ventilatory support with CPAP in the ICU but was successfully extubated the following day. Epidural analgesia provided effective postoperative pain control. The overall course was favourable, highlighting that meticulous planning, gradual decompression, and tailored ventilation and haemodynamic strategies can allow safe anaesthetic care even in extreme presentations of massive ascites.
What You Should Know
Giant ovarian tumours with massive ascites pose major risks during induction and decompression due to respiratory restriction and abrupt haemodynamic shifts.
Gradual drainage of ascitic fluid is critical to prevent cardiovascular collapse and re-expansion pulmonary oedema.
Combined general anaesthesia and epidural analgesia can improve intraoperative stability and postoperative pain control in selected patients with normal coagulation.
Ramped positioning, lung-protective ventilation, invasive monitoring, and proactive thermal management are essential components of care in these cases.
Key Points
Challenge: Extreme ascites (28 L) causing ventilatory compromise and high risk of haemodynamic instability.
Strategy: Careful preoperative assessment, ramped induction, lung-protective ventilation, slow ascitic drainage, and balanced fluid/colloid replacement.
Monitoring: Continuous invasive blood pressure monitoring with serial arterial blood gases to guide ventilation and perfusion.
Outcome: Successful tumour resection with short-term postoperative ventilatory support and effective epidural-based analgesia.
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