pediatric anesthesia case: biopsy of a mediastinal mass

[jennyboo]

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Planned procedure: Biopsy of a mediastinal mass

Reason for consult: Surgeon asks you to please take a look at this kid and do a consult on him because she wants to make him an add-on for tomorrow's OR schedule.

CC: Stridor & difficulty breathing

History of present illness:

13-year-old boy with no past medical or surgical history. Had some "wheezing" last month and went to the ER where they treated him for bronchitis and sent him home. Two weeks ago, was observed by parents to have tonic-clonic "seizure-like activity" lasting about a minute at home. Ambulance was called and they brought him to another hospital, where it's reported he had a repeat seizure in an MRI machine which resolved on its own.

On review of systems, Mom reports that for the past couple of weeks he has had increasing shortness of breath when lying flat and sleeps sitting up.

Found on subsequent radiological studies to have a large mass in the mediastinal with tracheal compression to a narrowest diameter of 6mm.

Past medical/surgical history: None
Allergies: None

You're doing the consult. What is your assessment and plan?

 

[IlDestriero]

Assessment: the kid is in the hurt locker, so are you if you're not careful.
Plan: Start scouring the CT scan with the radiologist for an easily accessible lymph node. Midaz, glyco, ketamine, local.👍
Additional questions:
How big is the mass and where is it located?
What level is the airway compression, how much?
Any compression of heart or vascular structures? What is the relationship between the mass and the heart and other major vascular conduits?
Echo results.

 

[IlDestriero]

I'm surprised that no one wants to discuss this case.

 

[pgg]

I'm surprised that no one wants to discuss this case.

I was waiting for the OP to respond to you to give more info - looks like an "ordinary" mediastinal mass so far, if there is such a thing, so I was waiting for the curveballs and weird stuff to come. 🙂


In general for mediastinal masses, I'd like to know about the mass itself, its size and location, and the degree to which it compresses or displaces other mediastinal structures. OP said tracheal narrowing is to 6 mm - this 13 yo kid may be adult sized but we could have trouble with the usual sized tube.

He has postural dyspnea which suggests induction may be fun. After induction or neuromuscular blockade the loss of negative intrathoracic pressure could result in airway collapse and create difficulty ventilating the patient, even with an ETT tube.

Primary goals for induction are to maintain spontaneous ventilation. This can be done lots of ways. Initially I would avoid muscle relaxants because the loss of spontaneous ventilation and negative intrathoracic pressure risks airway collapse. But after an endotracheal tube is placed and I've demonstrated the ability to ventilate the patient with positive pressure, relaxants would be acceptable. However, given an appropriate anesthetic depth, their use is not likely to be necessary, from either an anesthetic or surgical standpoint.

Intraoperative concerns are rapid blood loss due to surgical injury, pneumothorax, embolism, cardiovascular collapse, and difficulty ventilating. Mediastinoscopy risks compression of the innominate artery and cerebral ischemia so a right radial arterial line may be useful.

Anything else?

 

[usnavdoc]

I agree with PGG.

For the OP, rads guys will measure things out and thats great, but for our purposes you need to express this as a percent of normal diameter. So instead of saying narrowing to 6mm say x% compression or whatever. It gives you an idea as to how compromised the AW passages are. Also how deep does the mass go. What is involved etc...

This is one of those times where you have to look at the imaging. 50% compression is when things get a bit more serious.

 

[Salt Creep]

I know this is "just" a biopsy, but this kid has postural symptoms as noted above: my orals answer would include having a CT surgeon skilled with rigid bronch in the room, and possibly to prep the groin for bypass (if so, including having the pump and perfusionist in the room).

 

[Planktonmd]

It sounds like an anterior mediastinal mass that is compromising the airway.
This surgery is a biopsy only, which means that the mass is not going to decrease in volume at the conclusion of the surgery and the ability to extubate the kid is at best questionable.
I would discuss the case in detail with the parents and make them aware that I might not be able to extubate the patient at the end of the surgery I would also have a discussion with the surgeon because it seems to me that we need to resolve the airway obstruction as soon as possible which might require more than just a biopsy.
If the plan remains just a biopsy then I would proceed only if the family is open to the real possibility of keeping the kid intubated at the end.
The fact that there is 6mm remaining of the tracheal lumen is actually reassuring.
The OP forgot to mention at what level of the trachea the compression seems to occur: If the compression is close to the carina then this is a case that requires femoral access and getting ready for bypass.
If the compression is above the carina then you can proceed with mask induction while maintaining spontaneous breathing (assuming the kid does not appear difficult to intubate on the clinical exam.