Term 8 Week 1 (w/c 19/5/14)
Good morning and welcome to the start of a new term for Gasclass.
For novices and veterans to Twitter and Gasclass, remember there are no right or wrong answers here. Over the course of the day and week, additional information and feedback to your inqueries will be provided here. Please tag your Twitter responses with #gasclass so we can find it and include in our Storify summary.
This week we will be working on call in the OR/OT…
You are paged by interventional radiology around 4pm because they want to book an add-on image guided biopsy of a mediastinal mass in a 10 yo child. What are your initial thoughts?
A good start to the new term! A number of common concerns came up:
– What is the urgency of this case? Does it need to be done as an add-on after hours, or can it wait until the morning?
– Is there a role for preop steroids to shrink the mass, and how will that affect diagnosis and treatment?
– How symptomatic is the child? Is there stridor or SVC obstruction?
When you go to assess the child, you find out that he has been previously healthy, but over a course of weeks has become increasingly short of breath on exertion. He was getting breathless with sports and was initially prescribed a puffer that didn’t help, and now he gets winded walking up stairs. When questioned about sleeping positions, he has been sleeping on his side and now on his belly. He immediately gets short of breath on lying flat and has had an episode where he felt like he was going to pass out. There is no hoarseness, ptosis, or meiosis.
On physical examination, there are no signs of plethora or swelling of the face, but his neck and arm veins are visibly distended. He is not struggling to breath sitting up, but appears anxious.
The CXR shows a large central mass. The CT scan was done in the prone position, and it shows a large mass causing complete compression of the SVC with extensive chest wall collateralization. The trachea is compressed to >50% just above the carina, but the mainstem bronchi are unobstructed.
Are there any additional investigations that you would like?
Several people suggested getting an echo, which is important to look for compression of vessels and chambers as well as pericardial fluid. The echo showed no compression of the RA/RV, and unobstructed flow from the IVC. The SVC was complete obstructed. There was no pericardial effusion. Biventricular function visually appeared normal.
Some people suggested looking for a more superficial node to biopsy. Many would delay the case until the daytime, as well as having cardiothoracics available.
What are your anesthetic concerns and plan for this child’s needle biopsy? Does your centre have the resources or staffing to handle this case?
You decide to delay the case to daytime hours with full staffing and backup available. The procedure is planned to be done in IR under ultrasound guidance. The patient is positioned with a ramp and blankets to maintain more backup position, and light sedation with a benzodiazepine is given. He is quite cooperative during the initial local infiltration and scanning.
During the biopsy portion, the patient starts complaining of chest discomfort. He starts to cough and desaturate.
What is your differential and management plan?
Lung U/S and fluro in the IR suite rule out a significant pneumothorax. However, he is coughing more and continues to desaturate. He is beginning to become agitated, and is coughing up some frank blood.
How would you manage this emergency situation?
Thank you to everyone who read our blog and contributed to the discussion on Twitter! The summary of this week’s case can be found here.
Some of the salient points brought up with this case include:
– ECMO/CPB might be unfeasible and take too long to prevent neurological injury
– Ideally, an awake biopsy should be performed under local anesthetic and judicious sedation
– Pre-operative echo is important to determine any structural compression or effusion that may need to be drained
– May be safer to delay surgery until daytime hours
– Prudent to anticipate and plan for emergencies, and have rigid bronch, ENT/cardiothoracics/ECMO on standby for the highest risk patients
– RSI and paralysis in anterior mediastinal mass with airway compression may cause complete collapse and inability to ventilate. May be difficult to pass ETT past obstruction. Safer to maintain spontaneous ventilation during intubation.
– Preoperative steroids and radiation therapy (sparing part of tumour) may help in high risk cases, but need to discuss timing of biopsy with oncology to maximize diagnostic potential
Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol. 2007 Feb;20(1):1-3. PubMed PMID: 17211158
Blank RS, de Souza DG. Anesthetic management of patients with an anterior mediastinal mass: continuing professional development. Can J Anaesth. 2011 Sep;58(9):853-9, 860-7. doi: 10.1007/s12630-011-9539-x. Epub 2011 Jul 21. Review. English, French. PubMed PMID: 21779948.