Smaller anterior mediastinal mass

[caligas]

called to floor to intubate patient admitted with altered mental status and respiratory insuffiency.

CT "incidentally" found an anterior mediastinal mass 4x4x4 cm compressing left Innominate against trunks of brachiocephalic and common carotid. No tracheal involvement. Sats are 93% on Bipap, sitting upright. Airway looks fine. He is too awake for an awake look without fighting. Patient is on the floor, not icu. No icu bed ready at this point.

So: Prop-Roc-tube or take to O.R. (which is available) to do inhalation induction vs AFOI?

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[Arch Guillotti]

Propsuxtube.

 

[caligas]

Peopsuxtube.

So you feel it's not significant enough to cause any hemodynamic issues with muscle relaxation?

 

[vector2]

What's the reason for his sat and respiratory insufficiency? I'm more worried about this and possible cardiovascular collapse than the trachea. Would go to or, but if this was not feasible I'd slap on a high flow nasal cannula, give a slug of ketamine/glyco and awake dl/afoi

 

[caligas]

COPD but no clear cause for the exacerbation

 

[loveumms]

called to floor to intubate patient admitted with altered mental status and respiratory insuffiency.

CT "incidentally" found an anterior mediastinal mass 4x4x4 cm compressing left Innominate against trunks of brachiocephalic and common carotid. No tracheal involvement. Sats are 93% on Bipap, sitting upright. Airway looks fine. He is too awake for an awake look without fighting. Patient is on the floor, not icu. No icu bed ready at this point.

So: Prop-Roc-tube or take to O.R. (which is available) to do inhalation induction vs AFOI?

That is very high and I wonder if it's even in the anterior mediastinum (if it's where I am picturing, it's not but without looking at the scan myself I have no idea - for a quick anatomy review - http://teachmeanatomy.info/thorax/areas/anterior-mediastinum).

There is no airway involvement, thus I wouldn't be worried about airway compromise like I would be concerned with for typical large anterior mediastinal masses. It's also pretty small. Would be more worried about carotid flow but by not laying the patient completely flat after tube is in (or maybe propping them up a little to get the mass to move away from the carotid involvement), I wouldn't be concerned about this. I would use succinylcholine if he/she didn't have any contraindications.

 

[Ronin786]

That is very high and I wonder if it's even in the anterior mediastinum (if it's where I am picturing, it's not but without looking at the scan myself I have no idea - for a quick anatomy review - http://teachmeanatomy.info/thorax/areas/anterior-mediastinum).

There is no airway involvement, thus I wouldn't be worried about airway compromise like I would be concerned with for typical large anterior mediastinal masses. It's also pretty small. Would be more worried about carotid flow but by not laying the patient completely flat after tube is in (or maybe propping them up a little to get the mass to move away from the carotid involvement), I wouldn't be concerned about this. I would use succinylcholine if he/she didn't have any contraindications.

Given the prevalence of sugammadex, I'd venture you're better off using roc and reversing after the tube is in.

 

[Planktonmd]

So you feel it's not significant enough to cause any hemodynamic issues with muscle relaxation?

How does a mediastinal mass cause hemodynamic issues when combined with muscle relaxants???

 

[caligas]

How does a mediastinal mass cause hemodynamic issues when combined with muscle relaxants???

Classically there is concern about giving muscle relaxants to patients with mediastinal masses. (more so with masses larger than in my patient). The thinking is that positive pressure ventilation may be difficult or that relaxation of muscle tissues could contribute to compression of airway or large vessels.

 

[Planktonmd]

Classically there is concern about giving muscle relaxants to patients with mediastinal masses. (more so with masses larger than in my patient). The thinking is that positive pressure ventilation may be difficult or that relaxation of muscle tissues could contribute to compression of airway or large vessels.

Airway maybe, but large vessels... not really!
Where did you get that idea from?

 

[Orin]

This is why you always need to keep an iron lung around...

Seriously though, they have some newer ones out of plastic that are kinda sweet.

 

[chocomorsel]

Airway maybe, but large vessels... not really!
Where did you get that idea from?

In residency. And I think in books. I thought everyone learned that!

 

[chocomorsel]

This is why you always need to keep an iron lung around...

Seriously though, they have some newer ones out of plastic that are kinda sweet.

Is that real?

 

[Planktonmd]

In residency. And I think in books. I thought everyone learned that!

Maybe I somehow unlearned it?

 

[fakin' the funk]

called to floor to intubate patient admitted with altered mental status and respiratory insuffiency.

CT "incidentally" found an anterior mediastinal mass 4x4x4 cm compressing left Innominate against trunks of brachiocephalic and common carotid. No tracheal involvement. Sats are 93% on Bipap, sitting upright. Airway looks fine. He is too awake for an awake look without fighting. Patient is on the floor, not icu. No icu bed ready at this point.

So: Prop-Roc-tube or take to O.R. (which is available) to do inhalation induction vs AFOI?

Sure as **** not doing this in a ward room.

Wait for ICU bed...dude is "too awake to take a look" and oxygenating OK. If its gonna be hours, then fine go to OR but thats pretty ridiculous. Prop sux tube.

The mass is incidental, as you said. Treat the patient.

 

[caligas]

Sure as **** not doing this in a ward room.

Wait for ICU bed...dude is "too awake to take a look" and oxygenating OK. If its gonna be hours, then fine go to OR but thats pretty ridiculous. Prop sux tube.

The mass is incidental, as you said. Treat the patient.

Appreciate the insight. Unfortunately it WAS going to be hours for the ICU bed. I took him to the O.R. Its not that big a deal to do so here and that allowed him sit in PACU while his ICU bed got cleaned or whatever else they do for 3 hours.

In hindsight, agree what sux would have been fine. I let him breath himself down with Sevo and intubated easily without NMB. Good practice for the massive anterior mediastinal mass that I'll get called for next time.

 

[Planktonmd]

In my experience these anterior mediastinal masses are almost never the scary ones they told you about in residency, and you almost always can ventilate with mask and positive pressure.
Even the symptomatic ones where the patient is having dyspnea in the supine position are not as bad as you might imagine.
Also that whole thing about vascular compromise if you give a muscle relaxants is BS.

 

[vector2]

Airway maybe, but large vessels... not really!
Where did you get that idea from?

Uh, great vessel, heart compression, and CV collapse isn't exactly uncommon with mediastinal masses. An anesthesia resident at my institution had a case a couple months ago where the attending downplayed CT findings and the guy coded after he pushed the sux.

 

[Arch Guillotti]

Uh, great vessel, heart compression, and CV collapse isn't exactly uncommon with mediastinal masses. An anesthesia resident at my institution had a case a couple months ago where the attending downplayed CT findings and the guy coded after he pushed the sux.

Do you know what the CT findings were?

 

[Planktonmd]

Uh, great vessel, heart compression, and CV collapse isn't exactly uncommon with mediastinal masses. An anesthesia resident at my institution had a case a couple months ago where the attending downplayed CT findings and the guy coded after he pushed the sux.

How is giving a muscle relaxant going to cause the mass to press on the heart and the great vessels?
If the patient does not "code" in the supine position before induction there is no reason for him to code after induction unless you loose the airway.

 

[Hoya11]

How is giving a muscle relaxant going to cause the mass to press on the heart and the great vessels?
If the patient does not "code" in the supine position before induction there is no reason for him to code after induction unless you loose the airway.

I think the OP was confusing HD collapse with airway collapse in his own mind. It also makes no sense to me why this would cause any kind of airway difficulty. Actually a few things dont make sense about this story...

Why would they even tell you about this incidental finding in this acute situation that is unrelated? Are you going through the chart of the patient in detail as he is crumping ? Also what if you did decide to intubate him in the ward (which is strange but I guess if it takes 3hrs to get an ICU bed ok) what would you do with him? Let him sit there with an ETT and vent on the floor? Send him to ED? The situation makes little sense.. Prop SUX tube, dont overthink it.

I actually have seen a big mass cause airway compromise after induction. It was a big mass grossly visible to the naked eye though. Caused complete airway collapse and only able to ventilate with LMA until she was trached.

 

[deleted171991]

How is giving a muscle relaxant going to cause the mass to press on the heart and the great vessels?
If the patient does not "code" in the supine position before induction there is no reason for him to code after induction unless you loose the airway.

Actually there is, at least in my mind. (I might be wrong. I am speaking from personal knowledge/memory, not experience or books.)

As you probably recall, negative pressure ventilation is good for the right ventricle, while positive pressure is good for the left. I can imagine a situation in which, if one takes away (at least during inspiration) the negative pressure that pulls the tumor away from a compressed major vessel, there might be a complete collapse of the vessel, especially in a low pressure system such as the pulmonary arteries. And this cannot be fixed by anything, except maybe turning the patient and hoping that gravity will play the role of the pull chest excursion and negative imtrathoracic pressure play. This is why maintaining spontaneous ventilation is so important in big mediastinal tumors (and pericardial tamponade, as far as I remember).

I would also fluid load these people, to make sure they have enough intravascular volume, to decrease the chances for complete extrinsic vascular occlusion. (In case they have SVC syndrome, through a large bore lower extremity line.)

 

[Planktonmd]

Actually there is, at least in my mind. (I might be wrong. I am speaking from personal knowledge/memory, not experience or books.)

As you probably recall, negative pressure ventilation is good for the right ventricle, while positive pressure is good for the left. I can imagine a situation in which, if one takes away (at least during inspiration) the negative pressure that pulls the tumor away from a compressed major vessel, there might be a complete collapse of the vessel, especially in a low pressure system such as the pulmonary arteries. And this cannot be fixed by anything, except maybe turning the patient and hoping that gravity will play the role of the pull chest excursion and negative imtrathoracic pressure play. This is why maintaining spontaneous ventilation is so important in big mediastinal tumors (and pericardial tamponade, as far as I remember).

I would also fluid load these people, to make sure they have enough intravascular volume, to decrease the chances for complete extrinsic vascular occlusion. (In case they have SVC syndrome, through a large bore lower extremity line.)

Tamponade and anterior mediastinal mass are tow different things my friend!
And while your theory is conceivable I am not sure how realistic it is to see a patient with an anterior mediastinal mass causing such compromise of the great blood vessels to the point that the only thing keeping the patient alive is the negative inspiratory pressure!
This means during exhalation these vessels are probably collapsing and this patient will be unstable and symptomatic in the supine position without anesthesia!
How many patients like that have you seen?

 

[vector2]

Tamponade and anterior mediastinal mass are tow different things my friend!
And while your theory is conceivable I am not sure how realistic it is to see a patient with an anterior mediastinal mass causing such compromise of the great blood vessels to the point that the only thing keeping the patient alive is the negative inspiratory pressure!
This means during exhalation these vessels are probably collapsing and this patient will be unstable and symptomatic in the supine position without anesthesia!
How many patients like that have you seen?

The mechanism ffp describes is correct, negative pressure plus intrinsic chest wall tone keeps the svc and right heart patent. If the mass has significant infiltration into or around the pericardium you can have tamponade-like physiology. I would suspect the patient would have symptoms at rest, but I doubt this had to be the case 100% of the time. In the case I heard about, they gave him a couple compressions, some epi, tilted the table and he came back pretty quickly.

 

[Planktonmd]

The mechanism ffp describes is correct, negative pressure plus intrinsic chest wall tone keeps the svc and right heart patent. If the mass has significant infiltration into or around the pericardium you can have tamponade-like physiology. I would suspect the patient would have symptoms at rest, but I doubt this had to be the case 100% of the time. In the case I heard about, they gave him a couple compressions, some epi, tilted the table and he came back pretty quickly.

I have never seen a patient with anterior mediastinal mass who was asymptomatic pre induction and coded after induction!
What you are describing above could be anything... most likely some vagal reaction that was over treated with epinephrine and compressions!

 

[Noyac]

Everyone here has some decent points to consider and some truth to their argument. But what's important is the size of the Mass and the location of the Mass.

You don't get total collapse of airway or CV system from "small" incidental finding. Pts may not realize how impacted they are by these masses therefore your H&P needs to be focused. Things like SOB while lying down, wheezing, ankle or pretibial edema that is worsening, CHF symptoms, etc.

In this case I would not have been worried in the least. If you are worried that it is causing some collapse of the vessel then check pulse/BP on that side after induction. Is it the same as the left side? Collapsing this vessel will not cause total cardiovascular collapse with a mass this small. Maybe some edema to the right arm if you really want to stretch the possibilities. Maybe you would want to increase the BP like during a CEA once intubated.

I would have tried BiPAP if it had not already been attempted while waiting for ICU. I would have used sux and I would have given some neo and a bolus before any induction meds to keep BP up. I would not be babysitting this pt in the PACU while ICU takes their sweet time getting ready. That's nuts.