Establishing lung isolation under maintenance of spontaneous respiration using propofol and remifentanil in an infant with a life-threatening mediastinal mass

Introduction.Catheter-based diagnostic and therapeutic procedures are rapidly advancing. However, catheter related complications sometimes become life threatening. Cardiac tamponade is a rare but serious complication of this procedure. We have summarized one cardiac tamponade pejoration due to secondary coronary vessels laceration by the implanted pericardial drainage.Case report. A 4-year-old baby having Tetralogy of Fallot was posted for diagnostic catheterization study. Patient was induced with sevoflurane and spontaneous respiration was maintained. After catheter insertion to RV, dye was injected through the catheter which rapidly spread into the pericardial cavity indicating right ventricle perforation. Immediately, blood was aspirated under transthoracic echocardiographic guidance and hemodynamics started improving. For the provision of quick access to aspirate further collection, an intrapericardial sheath was inserted after multiple attempts. Patient’s condition started deteriorating again. TTE revealed again some collection and it was increasing gradually. On exploration, it was found that there was continuous bleeding from a lacerated epicardial vessel which contributed to the pericardial collection leading to further tamponade effect. This second iatrogenic injury complicated the management of the first iatrogenic cardiac perforation and, thereby, created a life-threatening situation which needed immediate surgical exploration.Discussion. Usual cause of tamponade after right ventricular perforation is bleeding from the RV, but in our case the second tamponade was not due to bleeding from the RV, but was rather from new laceration injury of epicardial vessels which was remained undiagnosed till exploration.

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Perioperative Cardiorespiratory Complications in Adults with Mediastinal Mass

Anesthesiology ◽

10.1097/00000542-200404000-00012 ◽

2004 ◽

Vol 100 (4) ◽

pp. 826-834 ◽

Cited By ~ 86

Author(s):

Philippe Béchard ◽

Louis Létourneau ◽

Yves Lacasse ◽

Dany Côté ◽

Jean S. Bussières

Keyword(s):

Pulmonary Function ◽

Mediastinal Mass ◽

Pulmonary Function Tests ◽

Signs And Symptoms ◽

Computed Tomography Scan ◽

Respiratory Complications ◽

Function Tests ◽

Postoperative Respiratory Complications ◽

Life Threatening ◽

Tomography Scan

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).

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Camouflagic presentation of a shwannoma as an anterior mediastinal mass with significant airway collapse -a case report

Journal of Society of Anesthesiologists of Nepal ◽

10.3126/jsan.v3i1.14632 ◽

2016 ◽

Vol 3 (1) ◽

pp. 44-46

Author(s):

Soumi Pathak ◽

Itee Chowdhury ◽

Ajay Kumar Bhargava

Keyword(s):

Mediastinal Mass ◽

Anaesthetic Management ◽

Endobronchial Ultrasound ◽

Anterior Mediastinal Mass ◽

Careful Evaluation ◽

Extrinsic Compression ◽

Airway Collapse ◽

Pressure Tests ◽

Life Threatening ◽

Central Airway

The anaesthetic management of diagnostic and surgical procedure in patients with anterior mediastinal mass presents life-threatening challenges. This is usually caused by extrinsic compression of the airway, obstruction to the venous return or cardiac output. Common symptoms of cardio respiratory compression are positional dyspnoea, orthopnoea, stridor, syncope, and superior venacaval syndrome. A previously asymptomatic person may develop catastrophic airway collapse or cardiovascular compromise under anaesthesia hence careful evaluation and discussion between a multidisciplinary team is essential. We report management of a case of shwannoma presenting as anterior mediastinal mass resulting in collapse of upper one third of trachea with twenty percentage luminal opening. The purpose of our reporting is to emphasise that patients with significant tracheomalacia and eighty percentage decreased tracheal lumen may be asymptomatic, thus a thorough evaluation and skeptical vigilance and pre-emptive thinking is required to deal with the challenges posed by them. The use of endobronchial ultrasound, impulse oscillometry and negative expiratory pressure tests may be valuable for assessing the cause of the central airway collapse and for further management of these patients.

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Propofol and remifentanil total intravenous anesthesia and the preservation of spontaneous respiration for a patient with mediastinal mass

Korean Journal of Anesthesiology ◽

10.4097/kjae.2013.65.6.583 ◽

2013 ◽

Vol 65 (6) ◽

pp. 583 ◽

Cited By ~ 2

Author(s):

Sung Kyu Rim ◽

Yu Bin Son ◽

Jong Il Kim ◽

Ji Heui Lee

Keyword(s):

Mediastinal Mass ◽

Total Intravenous Anesthesia ◽

Spontaneous Respiration ◽

Intravenous Anesthesia

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Successful Use of Extracorporeal Membrane Oxygenation for Respiratory Failure Caused by Mediastinal Precursor T Lymphoblastic Lymphoma

Case Reports in Medicine ◽

10.1155/2014/804917 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 7

Author(s):

Masafumi Oto ◽

Kyoko Inadomi ◽

Toshiyuki Chosa ◽

Shima Uneda ◽

Soichi Uekihara ◽

...

Keyword(s):

Respiratory Failure ◽

Tracheal Intubation ◽

Extracorporeal Membrane Oxygenation ◽

Mediastinal Mass ◽

Lymphoblastic Lymphoma ◽

Large Airways ◽

Life Threatening ◽

T Lymphoblastic Lymphoma ◽

Central Airway ◽

Vv Ecmo

Precursor T lymphoblastic lymphoma (T-LBL) often manifests as a mediastinal mass sometimes compressing vital structures like vessels or large airways. This case was a 40-year-old male who developed T-LBL presenting as respiratory failure caused by mediastinal T-LBL. He presented with persistent life threatening hypoxia despite tracheal intubation. We successfully managed this respiratory failure using venovenous (VV) ECMO. Induction chemotherapy was started after stabilizing oxygenation and the mediastinal lesion shrank rapidly. Respiratory failure caused by compression of the central airway by tumor is an oncologic emergency. VV ECMO may be an effective way to manage this type of respiratory failure as a bridge to chemotherapy.

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Ultrasound-Guided Anterior Mediastinotomy: A Feasible Tool for Critical Lymphoma Patients

Healthcare ◽

10.3390/healthcare9060770 ◽

2021 ◽

Vol 9 (6) ◽

pp. 770

Author(s):

Roberto Cascone ◽

Annalisa Carlucci ◽

Gaetana Messina ◽

Antonio Noro ◽

Mary Bove ◽

...

Keyword(s):

General Anesthesia ◽

Spontaneous Breathing ◽

Mediastinal Mass ◽

Diagnostic Yield ◽

Correct Diagnosis ◽

Rapid Onset ◽

Spontaneous Respiration ◽

Anterior Mediastinal Mass ◽

Neoplastic Tissue ◽

Surgical Biopsy

A significant part of all neoplasms growing in anterior mediastinum are lymphomas (25%). Achieving a correct diagnosis and a clear definition of a lymphoma’s subtype is crucial for beginning chemotherapy as soon as possible. However, most patients present a large mediastinal mass that compresses vessels and airway, with serious cardiorespiratory repercussions. Therefore, having multiple tools available to biopsy the lesion without worsening morbidity becomes fundamental. Patients enrolled in this study were unfit for a surgical biopsy in general anesthesia and the need to begin chemotherapy as fast as possible prompted us to avoid percutaneous fine needle aspiration to prevent diagnostic failures. Our observational study included 13 consecutive patients with radiological findings of anterior mediastinal mass. Ultrasonography was performed directly in the theatre to mark the lesion and to localize vessels and vascularized neoplastic tissue. Open biopsy was carried out in spontaneous breathing with a laryngeal mask and with short-acting medications for a rapid anesthesia, performing an anterior mediastinotomy. The mean operative time was 33.4 ± 6.2 min and spontaneous respiration was maintained throughout the procedure. No complications were reported. All patients were discharged in the first or second postoperative day after a chest X-ray (1.38 ± 0.5 days). The diagnostic yield of this approach was 100%. With the addition of ultrasonography right before the procedure and with spontaneous breathing, anterior mediastinotomy still represents a useful tool in critical patients that could hardly tolerate a general anesthesia. The diagnostic yield is high, and the low postoperative morbidity allows a rapid onset of chemotherapy.

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Managing Life-Threatening Malignant Superior Mediastinal Syndrome in Pregnancy: When Benefits of Radiation and Chemotherapy Outweigh the Risks—A Case Report and Review of Literature

Indian Journal of Medical and Paediatric Oncology ◽

10.1055/s-0041-1732819 ◽

2021 ◽

Vol 42 (02) ◽

pp. 208-212

Author(s):

Aashima Arora ◽

Gaurav Prakash ◽

Rashmi Bagga ◽

Radhika Srinivasan ◽

Arihant Jain

Keyword(s):

Mediastinal Mass ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

High Grade ◽

Multidisciplinary Management ◽

Review Of Literature ◽

Life Threatening ◽

Ionizing Radiation Exposure ◽

Superior Mediastinal Syndrome

AbstractThere is scarce literature on managing superior mediastinal syndrome during pregnancy. We report a case of 26-year-old primigravida who presented with life-threatening superior mediastinal syndrome at 32 weeks of gestation. The diagnosis was significantly delayed and, as a result, she reached the emergency with stridor and impending respiratory failure. She was diagnosed with primary mediastinal B cell lymphoma Lugano Stage II with a bulky mediastinal mass. She was treated with chemoimmunotherapy and underwent a preterm vaginal delivery after a week. She delivered a 1.6 kg healthy child with no malformations. Later, she completed three cycles of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisolone and five cycles of dose-adjusted etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin, rituximab, followed by radiotherapy. She continues to be in remission at 18 months of follow-up. Delaying diagnostic imaging that involves ionizing radiation exposure and chemotherapy to avoid teratogenic and obstetric complications during pregnancy can adversely affect the prognosis in certain patients with high-grade malignancies. On the contrary, prompt multidisciplinary management can lead to a gratifying outcome.

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Anesthetic Management of Anterior Mediastinal Masses in Children

10.1093/med/9780190685157.003.0052 ◽

2018 ◽

Author(s):

Mehdi Trifa ◽

Candice Burrier

Keyword(s):

Airway Obstruction ◽

Mediastinal Mass ◽

Perioperative Management ◽

Malignant Tumors ◽

Asymptomatic Patient ◽

Anesthetic Management ◽

Preoperative Evaluation ◽

Current Evidence ◽

Anterior Mediastinal Mass ◽

Life Threatening

The management of children presenting with an anterior mediastinal mass (AMM) is challenging for anesthesiologists. AMMs are a heterogeneous collection of primary or secondary, benign or malignant tumors. Severe and life-threatening complications related to airway obstruction and/or cardiovascular compression can occur in a patient with an AMM during anesthesia, even in an asymptomatic patient. It is important for the anesthesia provider to understand the pathophysiology of symptoms and complications and the current evidence regarding perioperative management of children with AMM. This chapter explores the pathophysiology of AMM symptoms and of AAM and anesthesia. Perioperative management of AMM patients, including preoperative evaluation and induction and maintenance of anesthesia, is also discussed.

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Perioperative Anesthetic Management of Anterior Mediastinal Mass

Anesthesiology: A Problem-Based Learning Approach ◽

10.1093/med/9780190850692.003.0006 ◽

2018 ◽

pp. 53-57

Author(s):

Alexandra Bastien

Keyword(s):

Airway Management ◽

Male Patient ◽

Mediastinal Mass ◽

Anesthetic Management ◽

Preoperative Evaluation ◽

Anterior Mediastinal Mass ◽

Mechanical Effects ◽

Life Threatening ◽

Perioperative Course

Patients with an anterior mediastinal mass pose as anesthetic challenges for the unsuspecting anesthesiologist. They are fraught with potential life-threatening issues during the patient’s perioperative course secondary to both the disease state and the mechanical effects of these masses. Once discovered, anterior mediastinal masses should involve planning with experienced anesthesia personnel skilled at complex airway management and in dealing with intraoperative and postoperative emergent complications. This chapter uses a case study of a 45-year-old male patient presenting for preoperative evaluation for an anterior mediastinal mass biopsy via Chamberlain procedure to illustrate the concepts associated with perioperative anesthetic management of anterior mediastinal mass.

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