1 pt, 1 large ant mediastinal mass, 2 cases

[deleted162650]

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Pt is a 31yo previously healthy male scheduled for "urgent" orchiectomy to remove a testicular mass. The pt initially presented with jaundice, and the ensuing work-up revealed RUQ mass with biliary compression, the aforementioned testicle, and a 10x8cm anterior medistinal mass. On CT, there is 30% tracheal compression, and the mass encircles the arch as well as SCV. Pt unable to lie supine due to SOB. Urology says testicle has to come out w/in 24H per standard of care for suspected malignancy (nevermind that if it is a testicular primary it's already widely metastatic). However just for arguments sake, let's say the guy presented with torsion and the case has to go now. Exam reveals a skinny dude with a favorable airway. No medical issues aside from the ones above. How you gonna proceed?

Part 2: Same pt on schedule 2 days later for ERCP w/ likely biliary stenting to relieve obstruction. Unable to drain galbladder percutaneously for some reason I don't quite remember. How you wanna tackle this one?

 

[ssmallz]

Where on the CT is the tracheal compression? Can we pass a single lumen past the narrowing?

 

[lushmd]

(1) Orchiopexy: Spinal
(2) ERCP: Prone MAC

 

[seamonkey]

awake FO intubation in sitting position (precedex?). Stay in that position until you confirm what airway looks like.

 

[PMPMD]

awake FO intubation in sitting position (precedex?). Stay in that position until you confirm what airway looks like.

Agree. Be ready to go lateral or prone if unable to ventilate after induction/supine positioning.

 

[ProRealDoc]

(1) Orchiopexy: Spinal
(2) ERCP: Prone MAC

"Pt unable to lie supine due to SOB"

 

[dhb]

"Pt unable to lie supine due to SOB"

He would probably do well prone...
I would try the same as lushmd

 

[MRW]

On CT, there is 30% tracheal compression, and the mass encircles the arch as well as SCV. Pt unable to lie supine due to SOB.

Awake FOB is not THAT much of a big deal and this is one situation that screams for it, imho...

edit: and for the ERCP, i'd use ketamine or ketamine/propofol

 

[Idiopathic]

consider cannulating groin for bypass, inhalation induction with thoracic/ENT ready with rigid bronch and bypass available. Where is the compression? pass a small tube into the right mainstem if necessary. Same management for both cases, i dont think you can do a MAC for him.

if you put this patient to sleep for the testicle and you dont make someone do the ERCP at the same time then I think thats a mistake.

 

[Idiopathic]

Awake FOB is not THAT much of a big deal and this is one situation that screams for it, imho...

why? this patient may or may not have dynamic airway compromise, but you probably wont appreciate it with them breathing spontaneously, so lets say you manage to do a FOI and see past the carina and have no obv compression so you place a tube 2 cm above the carina and go to sleep and then you cant ventilate.