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Review Note

Last Update: 02/17/2025 02:41 AM

Current Deck: ACG Part 2::Thoracic SSU

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SS_TS 1.6 Discuss the assessment of patients with mediastinal masses for surgical procedures including the assessment of severity of vascular and respiratory obstruction and the implications for anaesthesia management
Mediastinal masses:
  • Most commonly in the anterior mediastinum
  • Heterogenous group of benign and malignant tumours
    • Thymoma
    • Teratoma
    • Thyroid goiter
    • Lymphoma
    • Germ cell tumour
    • Thymic cyst
    • Parathyroid adenoma

Signs and symptoms:
  • Systemic: e.g.myasthenia gravis, thyroid disease
  • Local:
    • Tracheobronchial tree
      • Dyspnoea
      • Stridor/noisey breathing
      • Nonspecific cough
      • Chest discomfort
      • Tachypnoea
      • Rhonchi
      • Reduced breath sounds
    • Superior vena cava syndrome
      • Dyspnea
      • Headache
      • Facial and arm oedema
      • Visual disturbance
      • Altered mentation
      • Dilated collateral veins in the upper body
      • Pembertons positive
    • Right heart and pulmonary vascular compression
      • Dyspnea
      • Syncope during forced valsalva
      • Arrhythmias
      • Cardiac murmur

Pre-op:
  • History - Function, stability, severity
    • Quality of life
    • Can they lie flat? Cough when supine? Syncope?
    • Voice changes
    • Presence of orthopnoea
  • Examination:
    • Airway
    • Facial and arm swelling
    • Distended vessels
  • Investigations:
    • CT chest with contrast - look for mass size and location, relation to tracheobronchial tree, invasion into SVC or other large vessels, extent of compressive effects when supine for scan, airway diameter
    • CXR
    • Echo if suspicion of compression or invasion of cardiovascular structures or pericardial effusion suggested by CT
    • Spirometry - Often used but probably not very valuable test, if anything flow-volume loops (expiratory flow limitations show risk of airway collapse with anaesthesia)
  • Treatment:
    • If mass causing significant respiratory or cardiovascular compromise consider treatment with steroids, chemotherapy, radiotherapy to reduce mass size and alleviate obstruction (but may affect tissue diagnosis)
  • MDT:
    • Clear role for multidisciplinary discussion regarding need, type of surgery, risks. 
    • Should include:
      • Relevant surgical specialties e.g. cardiothoracics, ORL, paeds
      • Respiratory physicians
      • ICU
      • Anaesthesia
      • Radiologist
      • Pathologist when biopsy available
      • Oncology as appropriate if oncological diagnosis
      • In Auckland this occurs at the thoracic MDM

Intra-op:
Biggest concerns: Airway obstruction and cardiovascular collapse
  • Approach will be dependent on surgical approach:
    • Diagnostic vs therapeutic
    • Mediastinoscopy vs VATS vs thoracotomy vs sternotomy
    • Consider LA for biopsy/high risk surgery where able
  • Generally for sternotomy or thoracotomy/VATS = GA:
Airway: 
  • SLT or DLETT, may need AFOI with SLT then exchange for DLETT
  • Rigid bronchoscopy on standby if airway compromise
  • Elective cardiopulmonary bypass in high-risk cases
Breathing: 
  • Depends if intubation is distal to tracheobroncial obstruction, if distal IPPV ok
  • A lot of resources will say spontaneous ventilation however in practice (at least at Auckland) this is rarely done
  • Risk of worsening obstruction and venous return with IPPV
Circulation: 
  • Large bore IVL’s pre-induction, if SVC obstruction these need to be in the lower body
  • A-line
  • CVL in femoral vein if SVC obstruction to ensure drug delivery to effect site
  • High risk for bleeding as venous congestion ++ and vascular tumours often invading large blood vessels, consider cell saver/rapid infusion device
  • Blood should be immediately available
  • Careful use of IVF - excessive administration is an independent risk related to ALI

Choice of anaesthetic:
  • Consider short acting narcotics, short acting anaesthetic agents and reversible or short acting muscle relaxants
Positioning:
  • Will depend of surgical technique
Deterioration intra-op:
  • DDx is airway compromise vs cardiovascular collapse
  • Respiratory:
    • 100% FiO2
    • CPAP
    • Reposition - lateral, prone
    • IPPV with PEEP
    • OLV
    • Rigid bronchoscopy - can pass beyond obstruction under direct vision and ventilate distal to obstruction, care to avoid gas trapping
  • Cardiovascular:
    • Fluid bolus
    • Reduce depth of anaesthesia
    • Reposition - prone
    • Sternotomy and elevation of mass
    • ECMO


Emergence:
  • Can be complicated by airway obstruction especially for diagnostic surgeries when mass not removed
  • Risk of glottic oedema and post-op stridor in patients with long surgeries and SVC obstruction
  • Only extubate if patient is completely awake and obeying commands, full recovery of muscle strength (and it is a low risk case - see risk factors above)
Post-op:
  • Usually HDU if low risk, ICU if high risk - will need monitoring for airway compromise/oedema, cardiovascular monitoring
  • Pain relief should be multimodal and opioid-sparing, regional blocks for thoracotomy, and can consider for sternotomy

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