Anesthesia for Mediastinal Masses preop, intaop.pptx

Mediastinal tumors vary considerably in their nature and site of occurrence
Present the anesthesiologist with unique challenges
Locl symptoms: chestpain, dyspnea, dsphagia, headache, visual disturbances, sncope
Systemic symptoms: paraneoplastic syndrome, eaton lambert syndrome
CXR: mass location, relation to TB tree, compression effects, lung collapse
CT : quantifies degree of obstruction , tracheal diameter, cross section of trachea, mediastinal thoracic ratio, mediastinal mass ratio

. Echocardiography reliably identifies pericardial thickening and masses adjacent to the pericardium, and can evaluate myocardial dysfunction due to tumor compression or infiltration
This approach stemmed from the finding that an increased midexpiratory plateau when changing from the upright to the supine position is pathognomonic for a variable
intrathoracic airway obstruction and an indicator of patients who are at risk for airway collapse during induction of anesthesia
Decision
Risk stratifiation
Urgency
Type of procedure
There is increased CVP resulting in decreased flow in the SVC which may delay the onset of anesthetic and emergenc drugs and make their efficacy uncertain
Maintain spontaneous ventilation as far as possible (noli pontes ignii consumere) do not burn the bridges
Extra care should be aken in children (mildly symptomatic or asymptomatic)
higher rate of complications due to smaller size of thoracic cavity, more compressible and smaller tracheobronchial tree

The anesthesiologist should know the exact location of the mass and ots effect on surrounding anatomy
Induction should be performed in a stepwise manner and is usually a team approach with an effort to maintain adequate ventilation and circulation
Awake FOB intubation : under LA/minimal sedation is preferred technique as it is mostreversible technique which can be aborted at any point
If FOB intubation failed: rigid bronchoscope via venturi injector to maintain airway and oxygenation

In patients who have undergone diagnostic procedure/ surgeries where the mass is not removed completely removed emergence and recovery may be complicated by airway obstruction
Glottic edema and postoperative stridor may occur in patients with SVC obstruction and prolonged surgeries
Fibreoptic Bronchoscopy prior to extubation to Assess airway patency, Rule out tracheomalacia
Patient extubated only after Fully awake patient
Postoperative mechanical ventilation: Long duration of surery, Accidental resection of major nerves
Safe
Asymptomatic adult, CT minimal tracheal/bronchial diameter >50% of normal

Unsafe
Severely symptomatic adult or child
Children with CT tracheal/bronchial diameter 50% of normal
Mild/moderate symptomatic adult with CT tracheal/bronchial diameter 35% decrease :A/W respiratory sy

1. Anesthesia For Mediastinal Masses Presenter Moderator Pawan Rai Maj. Dr. Krishna Dhakal Anesthesia resident Consultant Anesthesiologist Dept. Of Anaesthesiology Dept. Of Anaesthesiology NAIHS NAIHS Date: 2082/05/12

2. Outlines Introduction Anatomy and pathology Clinical presentation Preoperative Evaluation Surgical Approaches Anesthetic Management Postoperative Care 2 26-Aug-25

3. Introduction Mediastinum is derived from Latin meaning “Midway” Middle space in the thoracic cavity Mediastinal tumors vary considerably in their nature and site of occurrence Present the anesthesiologist with unique challenges 3 26-Aug-25

4. Anatomy 4 ATOTW 320 – Anterior mediastinal masses in paediatric anaesthesia (25th Sept 2015) 26-Aug-25

5. Contents of Mediastinum 5 26-Aug-25

6. Mediastinal Masses Mediastinal masses can be benign or malignant, developing from the structures; Normally present in mediastinum That pass through mediastinum during development phase Metastasis of malignancies that arise elsewhere in the body 6 26-Aug-25

7. Mediastinal masses 7 26-Aug-25

8. Clinical Presentation Tracheobronchial obstruction Symptoms : dyspnea , noisy breathing, nonspecific cough, and chest discomfort Signs : tachypnea, stridor, rhonchi, and decreased breath sounds 8 26-Aug-25

9. Clinical Presentation Superior vena cava syndrome Headache, visual disturbance, altered mentation , dilated collateral veins in the upper body and edema of the face, neck, and arms Right heart and pulmonary vascular compression Dyspnea , syncope during a forced valsalva maneuver , arrhythmias, and cardiac murmur Systemic syndromes : myasthenia gravis and thyroid disease 9 26-Aug-25

10. Preoperative Evaluation Aims Identify the size, the relations of the mediastinal mass to the tracheobronchial tree and vital vascular structures The location and Extent of any compressive effects Evaluation of patient’s medical history, physical examination, current functional status, imaging To understand the proposed surgical procedure 10 26-Aug-25

11. History Routine history with specific to mediastinal mass History of local and systemic symptoms Assess for: Degree of severity of symptoms Exacerbating factors- change in position Actions which alleviate symptoms 11 26-Aug-25

12. Respiratory symptoms and signs History Cough Dyspnea on lying or exertion Orthopnea Cyanosis Physical examination Decreased breath sounds Stridor Cyanosis Rhonchi 12 26-Aug-25

13. Respiratory symptoms: Positioning Sitting position- Minimal tracheal compression Supine position – Can be severe due to effect of gravity on the mass and end expiratory increase in intrapleural pressure Positional compression is called “ Dynamic Compression ” Static tests- X-rays, CT may not give the true picture of physiological effects of compression 13 26-Aug-25

14. 14 Essential Clinical Anesthesia 26-Aug-25

15. Cardiovascular symptoms and signs History Fatigue Syncope Shortness of brath Orthopnea Cough Headache Physical examination Neck or facial edema Jugular venous distension Blood pressure instability Pulsus paradoxus papilloedema 15 26-Aug-25

16. Heart and great vessels involvement May infiltrate/compress heart, SVC, pulmonary arter Awake patient: pulmonary arterty is rarely compressed Supine position and loss of intrathoracic pressure during anesthesia Compression of PA Hypoxemia, hypotension, may lead to cardiac arrest 16 26-Aug-25

17. 17 Essential Clinical Anesthesia 26-Aug-25

18. Preoperative Investigations Assess the relationship of the mass to adjacent structures Since they are done in awake patient, they not always predict changes that can occur during induction of anesthesia 18 26-Aug-25

19. Preoperative Investigations Radiological CXR, CT scan, MRI: Useful for providing anatomical details of the lesions 19 26-Aug-25

20. Preoperative Investigations Echocardigraghy Patients with cardiovascular symptoms, or those unable to give an adequate history Assess for cardiac, systemic, or pulmonary vascular compression 20 26-Aug-25

21. Preoperative Investigations PFT: Postural spirometry 21 Essential Clinical Anesthesia 26-Aug-25

22. Preoperative Investigations Peak expiratory flow rate(PEFR) Reflects central airway diameter 22 26-Aug-25

23. Preoperative Investigations Awake fiberoptic bronchoscopy Allows direct visual assessment of the obstruction of proximal and distant airways Can provide information regarding dynamic compression of airway 23 26-Aug-25

24. Risk Assessment 24 Clinical Thoracic Anesthesia 26-Aug-25

25. Risk Assessment Grading of symptoms Asymptomatic Mild : Can lie supine with some cough/pressure sensation Moderate : Can lie supine for short periods but not indefinitely Severe : Cannot tolerate supine position 25 26-Aug-25

26. Risk Assessment CT scan indices Tracheal Diameter >35% decrease :A/W respiratory symptoms >50% decrease:A / Wcomplete obstruction during GA MTR >50% high risk of respiratory complications MMR <30% :small masses 31-41%: medium mass >45% : large mass 26 26-Aug-25

27. Risk Stratification Safe Asymptomatic adult , CT minimal tracheal/bronchial diameter >50% of normal Unsafe Severely symptomatic adult or child Children with CT tracheal/bronchial diameter <50% of normal, regardless of symptoms Uncertain Mild/moderate symptomatic child with CT tracheal/bronchial diameter >50% of normal Mild/moderate symptomatic adult with CT tracheal/bronchial diameter <50% of normal Adult or child unable to give history 27 26-Aug-25

28. Surgical Approaches Diagnostic Percutaneous CT-guided needle biopsy Biopsy of extrathoracic mass Anterior mediastinotomy Anterior mediastinoscopy Transbronchial needle aspiration Therapeutic Mediastinoscopy – Anterior, Cervical Sternotomy Thoracotomy Video-assisted thoracoscopic surgery 28 26-Aug-25

29. Anesthetic management Preparation Vascular access: central and peripheral line in lower half of the body Blood availability Planned epidural analgesia Planned CPB 29 26-Aug-25

30. Anesthetic management Monitoring ASA standard monitoring Preinduction invasive arterial and CVP line Airway pressure and volume monitoring In presence of cardiac/ pulmonary artery compression PA catheter CO monitors TEE BIS monitoring 30 26-Aug-25

31. Choice Of Anesthetic Technique 31 Principles and Practice of Anesthesia for Thoracic Surgery,2 nd Edition 26-Aug-25

32. Anesthetic management Premedication Antisialogogues , adequate LA if awake FOB planned Sedation avoided in presence of airway obstruction Induction Surgeon should be present Choice : Severity of symptoms Degree of anatomical and physiological disruption Imaging and nature of surgical procedure 32 26-Aug-25

33. Anesthetic management Induction and Intubation Spontaneous ventilation should be kept as far as possible Awake FOB intubation in sitting or lateral position Awake videolaryngoscopy ETT should be placed beyond the site of tracheal compresion ( reinforced tube) If FOB intubation failed: rigid bronchoscope Once sternotomy is performed and tumor lifted: degree of airway obstruction decreases 33 26-Aug-25

34. Rescue operations for airway obstruction Awaken patient as rapidly as possible Repositioning patient to comfort position Rigid bronchoscopy and ventilation distal to the obstruction CPB/ECMO 34 26-Aug-25

35. Anesthetic management Maintenance Maintenance of spontaneous ventilation as long as possible Use of muscle relaxant is controversial If require – short acting Avoided in presence of airway obstruction and lambert Eaton syndrome Pressure control ventilation to detect early increase in airway pressure 35 26-Aug-25

36. Anesthetic management Fluid therapy : Restrictive Preoperative <3ml/kg/hr Intraopertive limited to 1.5-2 lit in absence of hemorrhage Directed to maintain CO Replacement of blood loss with colloid/blood 36 26-Aug-25

37. Anesthetic management Extubation Fibreoptic Bronchoscopy prior to extubation Avoidance of coughing, bucking Patient extubated only after full recovery of reflexes, neuromuscular function Postoperative mechanical ventilation considered 37 26-Aug-25

38. Postoperative Care Monitoring for postoperative airway obstruction Tracheomalacia Patients with SVC obstruction: airway edema Multimodal analgesia Intensive postoperative monitoring especially after diagnostic procedures where the cause of obstruction has not been addressed 38 26-Aug-25

39. 39 Essential Clinical Anesthesia 26-Aug-25

40. 40 Essential Clinical Anesthesia 26-Aug-25

41. References Miller’s Anesthesia, Tenth Edition Clinical anesthesia 9 th edition Paul G. barash Essential Clinical Anesthesia Principles and Practice of Anesthesia for Thoracic Surgery, Second Edition 41 26-Aug-25

42. Thank You 26-Aug-25 42