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Dr Rafaat, can you do one CT guided Biopsy before you go home?

Dr Rafaat, can you do one CT guided Biopsy before you go home?. What I knew:. HPI: 15 year old, 60kg female, presenting to outside hospital with a 10 day history of fatigue, dyspnea and cough Additionally, had HA, night sweats and weight loss

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Dr Rafaat, can you do one CT guided Biopsy before you go home?

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  1. Dr Rafaat, can you do one CT guided Biopsy before you go home?

  2. What I knew: • HPI: 15 year old, 60kg female, presenting to outside hospital with a 10 day history of fatigue, dyspnea and cough • Additionally, had HA, night sweats and weight loss • PMHx: ex 26wk preemie, some “EKG abnormality”, recent hx of recurrent PNA • SurgHx: s/p PDA ligation • Something was going to be biopsied. • CT scan was from outside hospital, and was not in EPIC

  3. What I knew: • It was 5pm, most of ASMG had gone home, and CT is FAR AWAY from the OR • AND I sent the resident home, because this was “just a biopsy”

  4. What I Discovered: 11 x 7 x 11cm Anterior mediastinal mass

  5. Look at it, gently covering the trachea and SVC.

  6. Normal Structures in CT

  7. Marked compression of SVC with obstruction • Mild compression of branch PAs without obstruction • Right Pleural effusion

  8. Compression, without occlusion of bilateral mainstem bronchi

  9. Compression, right bronchus

  10. Mediastinal Compartments

  11. Mediastinal Masses • Of all mediastinal masses, 35%-55% arise in the anterior mediastinum • The most common types of tumor in the anterior mediastinum are known by the Four “T”s: • Teratoma • Terrible Lymphoma • Thyroid • Thymoma From Lerman, J Anterior Mediastinal Masses in Children, SeminAnes, Peri Pain, (26) 2007

  12. EKG

  13. Guesses?

  14. Wolff-Parkinson-White Syndrome • Due to an accessory pathway that bypasses AV node allowing reentry tachyarrhythmias • Pts at risk for PSVT and AF • Anesthetic management involves avoiding increases in sympathetic tone • Treat anxiety and pain • Maintain adequate intravascular volume • Avoid medications that may precipitate tachycardia (Ketamine, Glyco, Epi) • Neostigmine, by slowing conduction through the AV node, may encourage conduction through accessory pathway • Treatment is with Calcium channel blockers, beta blockers • NOT ADENOSINE ( can induce VF)

  15. Echo Echocardiogram showing SVC occlusion by the mass. RV was under filled. Echo otherwise showed preserved LV function and findings consistent with CT.

  16. What I Discovered • Pt severely orthopneic, has to sleep on many pillows. • Becomes dyspneic on exam at <45 degree head-up • Exam: • HEENT: slightly plethoric, some head/neck swelling. • Airway: MP 2, good mouth opening, TM distance and prognath • Resp: Bilateral crackles R>L, wheezes primarily on right • CV: RRR, no m/r/g, strong radial pulses • Abd: soft, NT • Neuro: Intact • During exam, pt experienced several long bouts of coughing that seemed to make not just her lips, but her entire head and neck blue.

  17. Problems • Anterior mediastinal mass • With SVC obstruction, branch PA occlusion, and some tracheal and mainstem bronchus compression • Resulting in: • SVC Syndrome • Dyspnea and orthopnea • WPW • I’m alone and far away from help

  18. SVC Syndrome • Mediastinal tumors are the primary natural cause of SVCS in children and adolescents • 50% of these are primary mediastinal tumors • Symptoms are secondary to impaired venous drainage of the head, neck and upper extremities • Worsen when supine, improve when upright • Can include dyspnea, facial and neck swelling, venous distention of neck and chest, wheezing and stridor

  19. SVC Syndrome: Brief Anesthetic Considerations • Neuro: Obstructed venous drainage may also lead to increased ICP • Important to maintain MAP to ensure CPP • Airway: Increased edema may increase risk of difficult intubation • Pulm: Positive pressure ventilation, by increasing intrathoracic pressure, may further decrease venous return • CV: Preload augmentation may be necessary to ensure adequate ventricular filling and maintenance of CO • Access: Obstructed upper extremity venous drainage necessitates lower body intravenous access

  20. Anterior Mediastinal Mass:Forces at Work • In the supine position, two opposing forces maintain the position of the tumor: • Negative Intrathoracic pressure – pulls the tumor up • Gravity – pulls tumor down • If the intrathoracic pressure is made less negative, gravity will win, and the tumor will compress underlying structures • Positive pressure ventilation • Cessation of spontaneous respiratory efforts • Sitting, lateral decubitus or prone positions direct force of mass towards abdomen, left chest or sternum • Instead of aorta, SVC and trachea

  21. Anterior Mediastinal Mass:Important Studies • EKG, Labs, etc… • Echocardiogram • Assess presence and degree of vascular or cardiac compression • SVC, RA, pulmonary arteries and pulmonary veins susceptible to compression due to low internal pressure • Function and pericardial involvement • CAT Scan • Assess size and position of mass • Effect on adjacent structures

  22. Anterior Mediastinal Mass: PFTs? • Several authors advocate routine measurement of PFTs • Dynamic measurement of presence and degree of obstruction • Can be done both seated and supine to assess functional changes • PFTs do little to help predict intraoperative morbidity and mortality in this population • No study to date has predicted perioperative airway complications from spirometry alone prospectively • Although, PFTs can help predict postoperative respiratory complications • Tracheal compression >50% on CT and Peak Expiratory Flow Rate < 40% • [Bechard P et al, Perioperative respiratory complications in adults with anterior mediastinal mass, Anesthesiology 2004]

  23. AMM: Basic Anesthetic Considerations • Maintain spontaneous ventilation • Awake/sedated FOB intubation if ETT necessary • Consider a partial left lateral decubitus position • Have a rigid bronchoscope ready • If tracheal compression occurs despite precautions and/or if ETT unable to be easily advanced in trachea • Lower extremity access • Have a quick way to flip pt prone • Consider CPB • In cases of severe vascular compression, cannulate for CPB while pt still awake.

  24. The Plan • Created a ramp on the CT scanner, ~30degrees • Plan to use local and nothing • In the words of one of my PICU attendings, Dr. Brad Peterson: • “Anesthesia’s a goddamned luxury. If they make it back to complain to you in a couple years, you’ve done a good job.” • Placed lower extremity IV • Small dose ketamine (0.25mg/kg) and glyco if sedation was necessary • I know, I know….. Fentanyl and Midaz would potentially lead to respiratory depression (especially in doses sufficient to allow pt to remain still), and propofol may increase venous capacitance, leading to even poorer venous return. • I chose the Devil I knew • Prepare for war • Epi, code drugs, LMA, etc.

  25. What Happened • Pt extremely anxious, almost hyperventilating • Could not lay on 30 degree ramp without significant dyspnea • Anxiety was definitely contributing to difficulties • Sat pt up, and explained again, carefully, why I wasn’t giving her any medication • Proceeded with 20mg Ketamine, preceded by 0.6mg Glycopyrollate

  26. What Happened • Pt was still, breathing comfortably with no evidence of obstruction, and laying on ramp. • Started coughing • Airway free of oral secretions • Improved with another 20mg ketamine.

  27. And Then..... • Pt began coughing again, and did not stop. • Sats started to drop. • Attempted to assist ventilation with bag and mask and 100% O2 • No appreciable help • Sats continued to drop..now in 70s and pt still coughing • Pts BP, which, up to this point was ~110/60, was dropping to 80/40

  28. And Then...... • Attempted to place LMA and deepen anesthesia with more ketamine • LMA 4 and 80mg ketamine • Ketamine administered with 10mcg EPI, given risk of circulatory collapse • LMA did not help, sats in 50% range, BP steady, HR in 130s • Copious frank blood began to come from pts nose and mouth • LMA insertion easy and atraumatic • Most likely secondary to increased venous pressure coupled with acutely elevated and sustained increase in intrathoracic pressure

  29. ........... • The patient required control of her airway and 100% O2 • For oxygenation, ventilation and protection from what seemed to be only upper airway blood • But was possibly on the verge of circulatory collapse secondary to mass compression of vasculature • Couldn’t paralyze, and didn’t want to give any further narcotics or sedatives • Waited until she took a breath in between bouts of coughing, saw where the bubbles were coming from, and slipped an ETT in

  30. ........ • Frank blood from ETT after placement • 100% O2 with GENTLE positive pressure and ~0.5 MAC of Sevoflurane • Sats returned, BP required continued boluses of Ephedrine and Epi, plus 1.5L Crystalloid. • Biopsies obtained • Left intubated, taken to PICU • Extubated next day without issue. Pt with no memory of event.

  31. What I learned • Better safe than sorry • a late, non emergent case, with a patient with this many issues, can be put off until there are a lot more hands around • Perhaps tried a slight decubitus position as well? • Especially in the face of the coughing. • Preparation is key

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