The anaesthetic management of children with anterior mediastinal masses

Abstract

SummaryChildren with anterior mediastinal masses may experience serious complications during general anaesthesia. We retrospectively surveyed the records of children with an anterior mediastinal mass who had been admitted to our hospital over a 7 year period. The presence of pre-operative symptoms or signs, findings of any special investigations performed and the anaesthetic outcome were noted. All radiological investigations were studied and tracheal compression measured. The majority of patients presented with severe clinical signs. There was a poor relationship between clinical signs and size of tumour or tracheal compression on CT scan. Corticosteroids were used prior to diagnosis in 33% of patients, all of whom were considered high risk. A clear diagnosis was made in 95% of these patients. The overall complication rate was 20% and 5% of patients had a serious complication related to anaesthesia. Stridor was the only sign that predicted an anaesthetic complication. Peri-operative respiratory complications were confined to patients with an isolated tracheal cross-sectional area less than 30% normal or less than 70% and associated with bronchial compression.

La prise en charge de l’anesthésie des patients avec une masse médiastinale antérieure

“…Positional dyspnea or orthopnea and stridor are potentially ominous signs and may predict the degree of tracheal compression, 6 pulmonary function abnormalities, 7 and the likelihood of complications. [7][8][9][10] If postural symptoms are identified, an effort should be made to define the position(s) in which symptoms are minimized. Cardiovascular symptoms may result from compression of the SVC, 11 pulmonary arteries, 2,12,13 or the heart itself.…”

“…17,20 Not surprisingly, the ''safe'' lower limit of tracheal CSA varies between studies and other lower limits have been proposed. 10 Definitive risk stratification on the basis of tracheal CSA and other potentially predictive factors is limited by the understandable tendency of most practitioners to modify anesthetic management or avoid general anesthesia completely in patients with the most severe findings. The lower limit of tracheal CSA compatible with the safe administration of general anesthesia is likely to vary based on patient characteristics, co-morbidities (e.g., chronic respiratory disease), as well as the size and positional relationship of the mass to the airway.…”

“…In a recent study, Hack et al found respiratory complications in only those children with tracheal CSA \ 30% of normal or tracheal CSA \ 70% if there was coexistent bronchial compression. 10 Moreover, the combination of left mainstem bronchial compression and right pulmonary artery compression has been reported to cause catastrophic complete ventilation-perfusion mismatch. 2,13 Anesthetic plan…”

“…Such risk stratification strategies have been previously proposed. 3,10,15 We use the following approach to classify patients: LOW RISK: Asymptomatic or mildly symptomatic, without postural symptoms or radiographic evidence of significant compression of structures; INTERMEDIATE RISK: Mild to moderate postural symptoms, tracheal compression \ 50%; HIGH RISK: Severe postural symptoms, stridor, cyanosis, tracheal compression [ 50% or tracheal compression with associated bronchial compression, pericardial effusion or SVC syndrome.…”

“…26 Mediastinoscopy and thoracoscopy can also be performed under local anesthesia in motivated patients. 27,28 The avoidance of general anesthesia and the use of local anesthesia alone or in combination with sedation has been reported in clinical series of adults 8 and children 7,10 with mediastinal masses.…”