![Page 1: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/1.jpg)
Anterior Mediastinal Masses
Peter Slinger MD, FRCPC
![Page 2: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/2.jpg)
25 y.o. F, Diag. Bx. Ant. Mediastinal Mass
? History
![Page 3: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/3.jpg)
Anterior Mediastinal Mass 25 y.o. Female
c/o cough + supine dyspnea x 2 mo.
? Px
? Investigations
![Page 4: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/4.jpg)
Flow
Expiration
RVTLC
PEFR
Volume
Inspiration
![Page 5: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/5.jpg)
Flow
Volume
Variable Extra-thoracic Airway Obstruction
![Page 6: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/6.jpg)
Flow
Volume
Variable Intra-thoracic Airway Obstruction
![Page 7: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/7.jpg)
Volume
Volume
![Page 8: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/8.jpg)
![Page 9: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/9.jpg)
Before Rx After Rx
Vol.
Neuman et al. Anesthesiology 60: 144, 1984
![Page 10: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/10.jpg)
Spirometry in Surgery for Anterior Mediastinal MassesHnatiuk O, et al. Chest 120: 1152-6, 2001
37 Adults: Thymoma, lymphoma, other tumor/cyst, etc.Mediastinotomy, mediastinoscopy, sternotomy, VATS10/27 Upright/supine spirometry, 4/10 a/w obstr. 4/4 GA no prob.15/27 dyspnea, 2/15 local anesth. ( 1 CT trach.compress + N flow/vol. loop)2 complications: tear SVC, pneumothorax
![Page 11: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/11.jpg)
Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease
Flow-Vol. Loopn=25
CT Trach.0-mild
CT Trach.Mod.
CT Trach.Severe
Normal11
8 3 0
Fixed Obstr. 7
3 1 3
Variable Extra-Thor 7*
5 2 0
Variab. Intra-Thor.0
0 0 0
( * No CT evidence of Extra-Thor. Trach. Obstuct. )(Vander Els, et al. Chest 2000; 117: 1256-61)
![Page 12: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/12.jpg)
Anterior Mediastinal Mass 25 y.o. F, c/o cough + supine dyspnea x 2 mo.Diagnostic Bx.
? Px
? Investigations
![Page 13: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/13.jpg)
![Page 14: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/14.jpg)
![Page 15: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/15.jpg)
Anterior Mediastinal Mass 25 y.o. F, c/o cough + supine dyspnea x 2 mo.Diagnostic Bx.
? Px
? Lab.
? Management
![Page 16: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/16.jpg)
Anterior Mediastinal Mass Concepts:
NPIC Anesthesia(Noli Pontes Ignii Consumere)
![Page 17: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/17.jpg)
Anterior Mediastinal Mass Concepts:
NPIC AnesthesiaPatients: safe/ unsafe/ uncertain for NPIC
![Page 18: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/18.jpg)
Anterior Mediastinal Mass Concepts:
Symptoms: dyspnea/coughvs. syncope
Symptoms: mild: supine no problemmoderate: supine some problemsevere: cannot lie supine
![Page 19: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/19.jpg)
Anterior Mediastinal Mass Concepts:
NPIC AnesthesiaPatients: safe/ unsafe/ uncertain Symptoms: mild/mod./severeProcedure: Diagnostic vs. Theraputic
![Page 20: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/20.jpg)
Anterior Mediastinal Mass Concepts:
NPIC Anesthesia Patients: safe/ unsafe/ uncertainSymptoms: mild/mod./severeProcedure: Diagnostic vs. TheraputicChildren vs. Adults
![Page 21: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/21.jpg)
Anterior Mediastinal Mass NPIC Anesthesia:
Safe: Asymptomatic adult no tracheal compressionUnsafe:
Severely symptomatic adult/child; child CT trach. compress. > 50%
Uncertain: all others
![Page 22: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/22.jpg)
20 y.o. F, Diag. Bx.Ant. Mediastinal Mass
? Management safe/ unsafe/uncertain
![Page 23: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/23.jpg)
Management for Uncertain Patients for “NPIC” Anesthesia:
ALL Patients:Determine optimal positioningSecure airway beyond stenosis if possibleRigid bronchoscope
Selected Patients:Helium/O2Prep. Chest for stenotomy, elevate mass
![Page 24: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/24.jpg)
Cardiopulmonary Bypass Standby?
![Page 25: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/25.jpg)
24 y.o. Male c/o Pre-syncope
Cardiovascular Compression
![Page 26: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/26.jpg)
Anterior Mediastinal Mass 20 y.o. FemalePost-op. mediastinoscopy/ biopsy
Severe dyspnea post-op. inRecovery Room
![Page 27: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/27.jpg)
![Page 28: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/28.jpg)
![Page 29: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/29.jpg)
![Page 30: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/30.jpg)
Perioperative Complications in Adults with Mediastinal MassBechard P, et al. Anesthesiology 100: 826-34, 2004
N= 105; M’scope, sternotomy, VATS, thoracotomy, other
Intraop. 4/105: hypotension/ AF/ hypox.predictors: pericardial effusion.
Postop. 11/105 (7 life-threat.): resp. fail., aletectasis, pneumonia
predict: preop. s/s,trach compress. > 50%,
![Page 31: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/31.jpg)
17 y.o. MaleGerm cell tumorL thoracotomy
![Page 32: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/32.jpg)
![Page 33: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/33.jpg)
![Page 34: Anterior Mediastinal Masses - Thoracic Anesthesia](https://reader034.vdocuments.us/reader034/viewer/2022051804/6281fd78af2be05c455d622e/html5/thumbnails/34.jpg)
Anterior Mediastinal Masses
History: dyspnea/cough, syncopeLab.: CT +/- EchoManagement: NPIC safe/unsafe/uncertainMyths: CPB standby, Flow/vol. loops Postop.