Anterior mediastinal mass

Question 1

Risk of death from what?

Answer 1

airway obstruction and/or CV collapse

Question 2

As for the anatomy-what are you looking for? how does this differ in kids?

Answer 2

location, size, degree of airway/CV compromise. In kids-tracheobronchial compression >50% preculudes safe GETA

Question 3

Causes of this mass? MCC?

Answer 3

Benign or malignant tumors, cysts or aneurysms. Most common-Hodgkin’s or NHL

Question 4

If it is unsafe to give GA-what are other options to get the tissue for diagnosis?

Answer 4

Extrathoracic mass/lymph node biopsy or CT guided needle biopsy or awake anterior mediastinoscopy with local anesthesia. Pt could also have chemo or radiation therapy

Question 5

Do these pts sometimes require ECMO or CPB?

Answer 5

Yes

Question 6

Hx you would expect from these pts?

Answer 6

Chest pain/fullness
Dyspnea, cough, orthopnea
Syncope
Hoarseness/dysphagia 
Or-they can be asymptomatic

Question 7

Physical exam of these patients:

Answer 7

Are they in acute distress?

stridor, cyanosis, SVC syndrome?

Question 8

Which lab tests/imaging would you like ?

Answer 8

CBC, CXR, chest CT, ECG, TTE, and +/- flow volume loop to see if its an intrathoracic obstruction

Question 9

Conflicts in this anterior mediastinal mass case:

Answer 9

Need for GA versus risk of cardiorespiratory collapse

Question 10

How can you optimize ant. mediastinal mass pts?

What if there is airway/vascular compression?

Answer 10

Maintain spontaneous ventilation until airway is secured or procedure is complete
If there is airway or vascular compression-if possible-awake patient, reposition (determine PRE-OPERATIVELY) which position causes less compression
rigid bronch and ventilation distal to obstruction
sternotomy and surical elevation of mass off compressed vessels
-If CPB is necessary-consider in pts with SEVERE postional sxs-establish prior to induction; will take too long if airway deteriorates

Question 11

Options for anesthesia in these cases:

Answer 11

general, local-may need awake fiberoptic

Question 12

Room setup:

Answer 12

a line (pre-induction) and on right side
ICU/Stepdown bed-maybe

Question 13

How will you induce pts with an mediastinal mass?

Answer 13

slow, titrated induction using spon ventilation. Sevo, propofol, ketamine
Rigid bronch equipment available

Question 14

How will you maintain these patients? (ant med mass)

Answer 14

Balanced anesthetic-manually ventilate to ensure positive pressure ventilation is possible BEFORE paralyzing.

Question 15

Emergence-

Answer 15

ensure ventilation is maintained-be careful of post anesthetic obstruction .

Question 16

Which structures can these mediastinal masses compress?

Answer 16

Tumors (thymoma, teratoma, thyroid CA, lymphoma, hygroma, cyst) of the anterior mediastinum cause obstruction of three structures: the tracheobronchial tree, the main PA (and atria) and the SVC.

Question 17

Why do more mediastinal mass deaths occur in children?

Answer 17

because their airways are more compliant and they less commonly manifest symptoms

Question 18

How can you prevent mediastinal mass from compressing main PA?

Answer 18

Maintenance of preload, PA pressure, and cardiac output may attenuate compression of the main PA.

Question 19

Why can GA be dangerous for mediastinal masses?

Answer 19

Postulated reasons for the dangers of general anesthesia
include the fact that lung volume is reduced under general
anesthesia and relaxation of bronchial smooth muscle leads to
greater compressibility of the airway from the overlying mass

Question 20

Where would you place the a line in pts with anterior mediastinal mass?

Answer 20

right radial artery because it allows us to know when there is compression of the innominate artery