Perioperative respiratory complications in pediatric patients with mediastinal masses: a report of 2 cases

General anesthesia in patients with mediastinal masses can lead to life-threatening cardiorespiratory complications. We report the cases of 2 pediatric patients with mediastinal masses who developed serious complications during general anesthesia. The first was a 13-year-old boy with a suspected diagnosis of high-grade T-cell non-Hodgkin lymphoma, lymph node disease, and an anterior mediastinal mass. He developed negative pressure pulmonary edema secondary to severe upper airway obstruction in spontaneous ventilation. The second was a 14-year-old boy with Rosai-Dorfman disease and paratracheal lymph node involvement. He developed severe airway obstruction in the early postoperative period. The anesthetic difficulties that arise in these cases include acute airway occlusion, superior vena cava syndrome, pulmonary artery or cardiac compression, acute pulmonary edema, and cardiopulmonary collapse. The technique of choice is induction with inhaled anesthetics and maintenance of spontaneous ventilation. Neuromuscular relaxants are avoided.     

Mediastinal tumors in children: apropos of 2 cases

General anesthesia in patients with mediastinal tumors has specific problems that need careful evaluation before surgery. Sometimes, mediastinal masses may result in life threatening complications, such as upper airway obstruction, superior vena cava syndrome, cardiac or pulmonary artery compression and acute pulmonary edema. After a review of the literature related to death during general anesthesia in children with mediastinal tumors, we emphasize the importance of the agreement between oncologists, surgeons and anesthesiologists for a sound diagnosis of these patients. We report two patients which illustrate the possibility of airway obstruction during anesthesia. The first was a 13-year-old female with an anterior and mean mediastinal tumor who had severe respiratory complications during general anesthesia for biopsy of cervical lymphadenopathy . The second patient was a 2-year-old female with anterior mediastinal and paratracheal masses and severe respiratory compromise, who was operated under general inhalation anesthesia and spontaneous breathing for biopsy of supraclavicular lymphadenopathy, after a meticulous preanesthetic evaluation. In these patients, the anesthetic procedure is a challenge to the anesthesiologist. Inhalation induction in a half seated position is recommended, maintaining the patient with spontaneous ventilation with halogenated agents and avoiding muscle relaxants.     

Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis

Objectives: To review perioperative airway management and ventilation strategy during the surgical removal of papilloma under suspension laryngoscopy in pediatric patients with severe airway obstruction. Methods: Seventy pediatric patients with degree III and IV laryngeal obstruction who underwent suspension laryngoscopy to remove laryngeal papillomatosis, between July 2005 and March 2009, were included in the study. All patients were intubated initially to secure the airway. Controlled ventilation through an endotracheal (ET) tube was used during the papilloma debulking near the glottis vera. Spontaneous ventilation or apneic technique was adopted based on the stage of the surgical procedure and the location of the remaining tumor. Hemodynamic parameters, pulse oxygen saturation (SpO₂), and CO₂ were closely monitored, and adverse events were recorded. Results: The duration of the surgical operation and the duration of the extubation period were 5–35 min and 5–20 min, respectively. Thirty cases with degree III and twenty cases with degree IV laryngeal obstruction received inhalation induction. Sixteen cases with degree III laryngeal obstruction were given an intravenous induction. Four patients admitted with a comatose status were emergently intubated without any anesthetics. The ET tube size was determined by assessing the opening through the tumor mass or glottic aperture under direct laryngoscopy. SpO₂ was maintained above 97% after the airway was secured and sufficient ventilation established. Controlled ventilation was used in all children during the bulk removal of tumor. Spontaneous respiration and apneic technique were adopted for the removal of the remaining tumor in the hypolarynx or trachea in 16 and 28 cases, respectively. Three patients had to be re‐intubated postoperatively because of persistent desaturation or laryngospasm. Conclusion: Key points of perioperative airway management in pediatric patients with papillomatosis‐induced severe laryngeal obstruction include careful preoperative airway evaluation; the proper choice of induction methods, and ET tube size; maintenance of an adequate depth of anesthesia; and flexible ventilation strategy, continuous and close monitoring during the extubation and postextubation period; and prompt management of adverse events.     

General anesthesia prior to treatment of anterior mediastinal masses in pediatric cancer patients

Many children with malignant diseases who present with an anterior mediastinal mass must undergo general anesthesia for tissue diagnosis or tumor resection. One hundred sixty-three pediatric patients over a period of 6 yr were admitted to Memorial Sloan-Kettering Cancer Center with a diagnosis of anterior mediastinal mass. Forty four of these patients required surgery and their records were reviewed. In recent years perioperative radiation therapy has been advocated for this patient group prior to their receiving general anesthesia. If a tissue diagnosis has not been made, preoperative radiation therapy may distort histologic findings and prevent accurate diagnosis. All patients with an anterior mediastinal mass who must receive general anesthesia in our institution do so prior to treatment with radiation or chemotherapy even in the presence of cardiovascular or respiratory symptoms. No patient died or sustained permanent injury as a result of their anesthetic or operative experience. Two patients who experienced difficulty on induction of anesthesia required tracheal intubation with a rigid bronchoscope. Two patients developed airway obstruction during anesthetic maintenance that was corrected with changes in patient position. Four patients were unable to have their tracheas extubated at the conclusion of surgery and one patient required tracheal reintubation in the immediate postoperative period. These patients were treated with radiation therapy and chemotherapy after tissue for diagnosis had been obtained. The authors conclude that in the absence of life-threatening preoperative airway obstruction and severe clinical symptoms general anesthesia may be safely induced prior to radiation therapy.     

Large mediastinal tumor in a neonate: an anesthetic challenge

Mediastinal tumors pose a grave risk of cardiopulmonary complications during the perioperative course, particularly in neonates and small children. These tumors can cause displacement and compression of vital thoracic structures such as the tracheobronchial tree, the heart, and the great vessels. Catastrophic complications often occur during induction of anesthesia, use of muscle relaxants, positioning, and at the time of extubation. We present our experience of anesthetic management of a neonate with a mediastinal mass who had features of both airway and vascular obstruction.     

Anesthetic management of patients with an anterior mediastinal mass: Continuing Professional Development

Purpose

Many cases have been reported of hemodynamic and airway collapse induced by general anesthesia in patients with an anterior mediastinal mass. We examined the literature for predictors of perioperative risk, guidelines for preoperative investigations, and strategies for management of the patient with a mediastinal mass.

Principal findings

In patients with an anterior mediastinal mass, symptoms may range from none to severe and may include orthopnea, stridor, cyanosis, jugular vein distension, or superior vena cava syndrome. In limited case series, incidences of serious complications up to 20% were noted, but these are primarily pediatric studies with unclear relevance to adults. There is a paucity of evidence providing guidance on quantifying risk and planning the safe conduct of anesthesia. In the largest adult case series to date, intraoperative complications were associated only with the preoperative presence of a pericardial effusion. Postoperative complications were predicted by severe symptoms at presentation, tracheal compression of > 50%, and a mixed obstructive-restrictive picture on pulmonary function testing. Low-risk patients tolerate conventional general anesthesia with neuromuscular blockade and positive pressure ventilation. Those at intermediate or high risk are best managed with the maintenance of spontaneous ventilation, at least initially. Cardiopulmonary bypass remains the option of last resort.

Conclusions

It appears prudent to avoid general anesthesia when possible for patients at the highest risk. When general anesthesia is required, a comprehensive plan must be formulated preoperatively with the surgical team. Cardiopulmonary bypass requires time for implementation, so it should be considered early and appropriate preparations should be made prior to the initiation of anesthesia.     

Dexmedetomidine for anesthetic management of anterior mediastinal mass

Anesthetic management of anterior mediastinal masses (AMM) is challenging. We describe the successful anesthetic management of two patients with AMM in which dexmedetomidine was used at supra-sedative doses. Our first case was a 41-year-old man who presented with a 10 × 9 × 11 cm AMM, a pericardial effusion, compression of the right atrium, and superior vena cava syndrome. He had severe obstruction of the right mainstem bronchus, distal trachea with tumor compression, and endobronchial tumor invasion. Our second case was a 62-year-old man with tracheal and bronchial obstruction secondary to a recurrent non-small-cell lung cancer mediastinal mass. Both patients were scheduled for laser tumor debulking and treatment of the tracheal compression with a Y-stent placed through a rigid bronchoscope. Both patients were fiberoptically intubated awake under sedation using a dexmedetomidine infusion, followed by general anesthesia (mainly using higher doses of dexmedetomidine), thus maintaining spontaneous ventilation and avoiding muscle relaxation during a very stimulating procedure. The amnestic and analgesic properties of dexmedetomidine were particularly helpful. Maintaining spontaneous ventilation with dexmedetomidine as almost the sole anesthetic could be very advantageous and may reduce the risk of complete airway obstruction in the anesthetic management of AMMs.     

Perioperative complications in children with Apert syndrome: a review of 509 anesthetics

Objectives: To perform a retrospective, anesthesia case note review in children with Apert Syndrome. Aim: To identify perioperative complications in this group of patients. Background: Apert syndrome is a rare autosomal dominant disorder characterized by craniosynostosis, craniofacial anomalies, and severe symmetrical syndactyly (cutaneous and bony fusion) of the hands and feet. Children with this syndrome require general anesthetics for a number of different operations and procedures. Our institution has records of 71 children with Apert syndrome. Analysis of their general anesthetic records was undertaken, and the incidence of perioperative complications was investigated. Methods: A retrospective case note review was performed on 61 children with Apert syndrome over a 14‐year period. There were a total of 509 general anesthetics administered to these children during this period of time. Results: There were a total of 31 perioperative respiratory complications occurring in 21 patients (6.1% of the total cases). Twenty‐three of these complications were supraglottic airway obstruction (4.5% of total cases). Conclusions: We found there to be a low incidence of major perioperative major complications in this group of patients. Nevertheless, a significant proportion of these children have obstructive sleep apnoea and may develop supraglottic airway obstruction on induction and emergence from anesthesia due to the associated mid‐face anatomical abnormalities.     

Anesthetizing the obese child

The prevalence of childhood obesity is increasing. The focus of this review is the special anesthetic considerations regarding the perioperative management of obese children. With obesity the risk of comorbidity such as asthma, obstructive sleep apnea, hypertension, and diabetes increases. The obese child has an increased risk of perioperative complications especially related to airway management and ventilation. There is a significantly increased risk of difficult mask ventilation and perioperative desaturation. Furthermore, obesity has an impact on the pharmacokinetics of most anesthetic drugs. This has important implications on how to estimate the optimal drug dose. This article offers a review of the literature on definition, prevalence and the pathophysiology of childhood obesity and provides suggestions on preanesthetic evaluation, airway management and dosage of the anesthetic drugs in these patients. The authors highlight the need of supplemental studies on various areas of the subject.     

Airway collapse with an anterior mediastinal mass despite spontaneous ventilation in an adult

Patients with anterior mediastinal masses are at increased risk for perioperative complications. Our case demonstrates that airway collapse and inability to ventilate may occur in the asymptomatic adult despite spontaneous ventilation with inhaled anesthesia and an endotracheal tube. Given the sudden and profound presentation of cardiopulmonary collapse, rigid bronchoscopy should be immediately available to facilitate life-saving ventilation. Though repositioning the pediatric patient lateral or prone has been reported to reestablish airway patency, this maneuver may be of limited benefit in the adult population because of a more ossified and developed chest wall. Lastly, if a high-risk patient requires a general anesthetic, strong consideration should be given to preinduction placement of femoral cardiopulmonary bypass cannulae and the availability to immediately initiate cardiopulmonary bypass.     

Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese

Background: Consistent with the increasing prevalence of obesity in the United States and many countries worldwide, anesthesiologists are now presented with a greater number of adult and pediatric patients who are significantly overweight. This prospective study was designed to examine the relation between age-adjusted body mass index, preoperative comorbidities, and perioperative outcome in children.

Methods: Children aged 2-18 yr undergoing noncardiac elective procedures were classified as overweight or obese based on their age- and sex-adjusted body mass index. Information was elicited regarding patient demographics, presence of comorbidities, and anesthetic technique. Data regarding the incidence and severity of perioperative adverse events were collected prospectively.

Results: Two thousand twenty-five children comprised the sample (1,380 normal weight, 351 overweight, and 294 obese). Obese children had a significantly higher prevalence of comorbidities than nonobese children, including asthma, hypertension, sleep apnea, and type II diabetes. Furthermore, obese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea.     

前纵隔肿瘤的围术期麻醉管理

背景 前纵隔肿瘤对循环、呼吸影响重大,给手术麻醉带来极大挑战. 目的 为前纵隔肿瘤手术麻醉方案的制定和后续研究提供参考. 内容 对近年前纵隔肿瘤手术麻醉相关的病例进行回顾分析. 趋向 全身麻醉风险分级为“不安全”的前纵隔肿瘤患者应尽量避免全身麻醉,无法避免者,应在充分评估及准备下实施,术前在局部麻醉下行股动静脉穿刺,备体外循环是有必要的.全身麻醉诱导时,应在最适体位下缓慢进行,保持自主呼吸,只有当插管顺利且确保在气管内时,才可使用肌松剂.术中突发通气困难,在纤维支气管镜引导定位失败后,应紧急建立体外循环.术后拔除气管导管应在充分评估气道后实施.     

Anesthetic implications of primary cardiac tumors in infants and children

OBJECTIVE: To determine the degree of hemodynamic and airway compromise in infants and children undergoing anesthesia for primary cardiac tumors. DESIGN: Retrospective study. SETTING: Tertiary-care, academic children's hospital. PARTICIPANTS: Patients <18 years old who had undergone anesthesia and surgery for resection or biopsy of a primary cardiac tumor (n = 25). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Charts were reviewed for intraoperative complications, defined as (1) hypotension (20% decrease from baseline) during or after induction; (2) failure to gain airway control by insertion of an airway or endotracheal intubation, inability to ventilate after administration of a muscle relaxant, need for change in patient position, rigid bronchoscopy, or cardiopulmonary bypass for adequate oxygenation; and (3) new arrhythmias. Hypotension during induction occurred in 4 patients (16%), 3 of whom were hemodynamically unstable preoperatively. Hypotension after induction was found in 2 (8%) patients. Hypotension occurred more frequently in patients with obstruction to blood flow and arrhythmia (n = 3), obstruction to blood flow only (n = 1), and arrhythmia only (n = 1). No patient had airway difficulty related to the tumor, although one intrapericardial tumor mimicked an anterior mediastinal mass. New arrhythmias occurred in 3 (12%) patients. CONCLUSIONS: The subgroup of patients at greatest risk are patients with a combination of obstruction to blood flow and arrhythmias. Despite the alarming diagnosis, the intraoperative course tends to be fairly stable in most cases. Extensive pericardial tumors may produce the same airway concerns as anterior mediastinal masses, but airway complications do not seem to be a problem with intrachamber tumors.     

Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal lymphoblastic lymphoma

Lymphoblastic lymphoma, an aggressive mediastinal mass, is recognized as serious threat to the patient in developing cardiac tamponade or airway obstruction. Surgical procedure is often required to relieve clinical emergency and to establish prompt pathological diagnosis. However, in such a patient, acute respiratory occlusion in the spine position can be a life-threatening complication during general anesthesia. We describe a 17-year-old man whose cardiac tamponade was treated by pericardial-pleural window through a left anterior thoracotomy in the lateral position. The patient recovered from hemodynamic compromise without showing respiratory occlusion during general anesthesia and remained in the lateral position until extubation. Pathological diagnosis was precursor T-lymphoblastic lymphoma. There were no complications attributable to the operative procedure. Further chemotherapy reduced the mediastinal mass in size after two weeks when the patient developed sepsis and died. Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal tumor with airway obstruction.     

Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation

Abstract

Objective: To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCIs) undergoing mechanical ventilation.

Design: Review of a prospectively collected database.

Setting: Intensive and intermediate care units of a monographic hospital for the treatment of SCI.

Participants: Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy.

Outcome measures: Demographic data, data relevant to the patients’ neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality.

Results: Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (≥7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low.

Conclusion: Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU.     

Perioperative management with epidural anesthesia for a parturient with superior vena caval obstruction

Perioperative management of patients with superior vena cava obstruction presents an anesthetic challenge because of severe cardiopulmonary compromise. This is particularly important in the parturient because of increased upper airway edema and inferior vena caval compression. We describe the management of a parturient who presented at 34 wk of gestation with signs and symptoms of superior vena cava obstruction from metastatic breast cancer. The patient was scheduled for a cesarean delivery followed by chemotherapy, as other therapies were deemed excessively risky because of the anatomic characteristics of the large mediastinal mass. This report describes the successful use of regional anesthesia in this setting and discusses the relevant anesthetic and perioperative management considerations for this complex scenario. IMPLICATIONS: Perioperative management of patients with superior vena caval obstruction presents an anesthetic challenge because of the severe cardiopulmonary compromise. This case report describes a parturient who presented for cesarean delivery with superior vena caval obstruction resulting from metastasis from breast cancer.     

Life-threatening airway obstruction as a complication to the management of mediastinal masses in children

Life-threatening airway obstruction from large mediastinal masses in children poses a difficult diagnostic and therapeutic dilemma, requiring the close coordination of a pediatric surgeon, anesthesiologist, radiologist, and oncologist. To focus on this problem, the anesthetic and surgical management of 50 consecutive children with mediastinal masses treated between 1978 and 1984 were reviewed. Thirty children presented with respiratory symptoms; nine had life-threatening respiratory compromise with dyspnea, orthopnea, and stridor. Thirteen of these symptomatic children had marked compression of the trachea and/or mainstem bronchi on radiographic studies. The tracheal cross-sectional area which was measured by computed tomography was decreased by 35% to 93% of the normal tracheal dimensions in these children. Nonresectable malignant neoplasms including lymphoma, Hodgkin's disease, rhabdomyosarcoma, and neuroblastoma were the eventual diagnoses in 10 of these patients. The other 3 patients were less than 4 years old and had benign lesions. General anesthesia was judged to be prohibitively risky in 5 of 13 patients. The diagnosis was established by node or needle biopsy under local anesthesia, and general anesthesia was deferred until the compromised airway was alleviated by radiation and chemotherapy. General anesthesia with endotracheal intubation was administered to 8 patients, 5 of whom developed total airway obstruction. Using a variety of maneuvers, ventilation was reestablished in all 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Perioperative cardiorespiratory complications in adults with mediastinal mass: incidence and risk factors

BACKGROUND: Patients with a mediastinal mass are at risk for cardiorespiratory complications in the perioperative period. The authors' objectives were to evaluate the incidence of life-threatening intraoperative cardiorespiratory and postoperative respiratory complications in adult patients and to study the usefulness of clinical signs and symptoms, radiologic evaluation, and pulmonary function tests in the determination of the perioperative risk. METHODS: The authors reviewed the investigation and treatment of adult patients presenting with anterior or middle mediastinal masses for surgery under anesthesia between January 1994 and July 2000. RESULTS: Ninety-eight patients underwent 105 anesthetic cases. The incidences of intraoperative cardiorespiratory and postoperative respiratory complications were 4 in 105 and 11 in 105, respectively. No collapse of the airways occurred during anesthesia. However, a high incidence of early postoperative life-threatening respiratory complications was observed (7 in 105). In a multivariate logistic regression analysis model, perioperative complications were predicted by the occurrence of cardiorespiratory signs and symptoms at the initial presentation (odds ratio [OR], 6.2) and the presence of combined obstructive and restrictive patterns (mixed pulmonary syndrome) on pulmonary function tests (OR, 3.9). Intraoperative complications were associated with pericardial effusion on computed tomography scan (OR, 19.8). Postoperative respiratory complications were related to tracheal compression of more than 50% on preoperative computed tomography scan evaluation (OR, 7.4) and mixed pulmonary syndrome on pulmonary function tests (OR, 15.1). CONCLUSION: Obstruction of the airway in an adult with a mediastinal mass is a rare event in the intraoperative period. Nevertheless, caution should be observed for the occurrence of early postoperative life-threatening respiratory complications. Patient at high risk of perioperative complications can be identified by the occurrence of cardiopulmonary signs and symptoms at presentation, combined obstructive and restrictive pattern on pulmonary function tests, and computed tomography scan findings (tracheal compression > 50%, pericardial effusion, or both).     

Anterior mediastinal masses — A multidisciplinary pathway for safe diagnostic procedures

Objective

The objective of this study was to report our multidisciplinary diagnostic approach for patients with anterior mediastinal masses (AMM).

Craniofacial surgery and specific airway problems

Infants and children undergoing craniofacial surgery may present with a wide range of diseases and conditions posing an array of challenges to the anesthesiologist. Optimal perioperative care requires an understanding of these diseases and their impact on airway and anesthetic management. For those children with anomalies affecting airway anatomy, soft tissues of the head and neck, or skeletal mobility, advanced airway management techniques (ie, modalities other than direct laryngoscopy) may be required to secure the airway. Additionally, some craniofacial surgical procedures have direct implications on airway management, such as with Le Fort III midface advancement involving halo distractor application, where the distractor device precludes facemask ventilation. For all of these patients, the anesthetic and airway management plans must be tailored to the surgery being performed, the patient's specific conditions, and take into consideration all phases of perioperative care. In this review, we present some of the more commonly encountered craniofacial abnormalities affecting airway management.