A 7-year-old child presents with a 3-week history of shortness of breath and a cough that is worse at night. Chest x-ray reveals a large mass in the chest. He presents for a lymph node biopsy under general anesthesia.
Physical examination: No signs of respiratory distress or pallor with supine position; saturation 98% on room air.
Imaging: CT:Anterior mediastinal mass causing slight tracheal deviation to the right and 20% tracheal compression. Echocardiogram: Normal biventricular function; no evidence of external compression.
Anterior mediastinal mass can lead to life-threatening airway compression and impingement on the heart and great vessels, leading to cardiovascular collapse upon induction of anesthesia. Mortality is especially high in children, possibly because of a more pliable rib cage and difficulty in symptomatic assessment preoperatively. The most common causes of anterior mediastinal mass in children are Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and acute lymphoblastic leukemia.
Respiratory symptoms include dyspnea, orthopnea, cyanosis, cough, wheezing, and stridor. Acute respiratory failure is rare. Cardiovascular symptoms include syncope, sudden pallor, headache, and facial swelling that is worse with Valsalva, and on physical examination jugular venous distention, facial/neck edema, blood pressure changes with postural changes, and increased pulsus paradoxus.
Even asymptomatic children may have significant airway and cardiovascular compression and require imaging studies. CT scan, echocardiogram, and lung function tests are commonly obtained. Severe airway compression is indicated by a tracheal cross section <50% of predicted, severe narrowing at the level of a mainstem bronchus, or peak expiratory flow <50% of predicted. These patients may warrant further diagnostic procedures under local anesthesia with minimal sedation or empiric treatment with steroids, chemotherapy, and/or radiation prior to a general anesthetic. Childhood lymphomas are extremely sensitive to radiation and steroids and can shrink markedly following short courses of treatment. For this reason, part of the tumor may be shielded from radiation to make it available for further workup.
Determine what position provides symptomatic relief (for example, right lateral decubitus or head of bed elevated) and consider placing patient in that position during induction and possibly for the duration of the procedure.
Place an IV prior to induction, preferably in a lower extremity.
If cardiovascular symptoms are present, consider arterial line placement prior to induction.
Maintain spontaneous ventilation during induction with inhalational agent or IV agents (propofol-remifentanil infusion, dexmedetomidine-remifentanil infusion, or ketamine).
During induction, slowly take over control of ventilation; continuous positive airway pressure may be helpful.
If intubating, consider the use of a reinforced endotracheal tube, a smaller-sized tube, and mainstem intubation based on the area of compression.
Consider avoiding muscle relaxants, as they may decrease chest wall tone and increase the risk of airway compromise.
Have a rigid bronchoscope and operator (ear, nose, and throat [ENT] surgeon) available in the event of tracheal or bronchial collapse.
If cardiovascular collapse is a concern, preparation should be made for emergent initiation of cardiopulmonary bypass (prepare groins for femoral cannulation, prime pump, have a cardiothoracic surgeon present and scrubbed) or sternotomy to lift the mass.
Intensive care unit admission is usually necessary. The patient may remain intubated and postoperatively is at risk for respiratory and cardiovascular compromise.
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