Risk factors for anesthetic-related complications in pediatric patients with a newly diagnosed mediastinal mass.

Edition: November-Decemeber 2021

Campbell N, Tsai A, Reading B, et al. . Paediatr Anaesth. 2021;31(11):1234-1240. doi:10.1111/pan.14281

Study design  

Single centre, retrospective case review.

Aim

Identification of risk factors for anaesthetic-related complications in paediatric patients with any type of mediastinal mass.

Methods

CT scans of patients presenting to Children’s Mercy Hospital, Kansas City between 2008-2019 were queried for “mediastinal mass”. Cardiac and respiratory symptoms were recorded and a blinded radiologist reviewed the imaging.

The procedure, type of anaesthetic administered and choice of airway management were examined. Anaesthetic complications were classified as; desaturation <80%, blood pressure <30% of peri-operative baseline or loss of ETCO2.

Findings 

86 patients were identified. 48% of patients underwent mediastinal mass biopsy, 21% tumour resection and 11% had a lymph node biopsy. Anaesthetic type was intubation with sevoflurane (56%), IV ketamine and/or dexmedetomidine using a natural airway (35%), anxiolysis or sedation (7%) and laryngeal mask airway with sevoflurane.

Six patients experienced an anaesthetic related complication, the commonest being desaturation <80%. All were intubated and had preoperative respiratory symptoms. Five experienced a reduction in BP or loss of ETCO2. Three, already had an ETT in situ (from ICU or the radiology suite).

Commentary

Morbidity remains high for children undergoing anaesthesia for procedures directly and indirectly related to mediastinal masses. As they are uncommon, any risk scoring system to predict those at highest risk would be beneficial. More than one preoperative respiratory symptom and tracheal compression on CT imaging were factors most predictive of anaesthetic complications, similar to previous reviews. The absence of pre-procedure orthopnoea and size and location of mediastinal masses were not predictive of incidences of anaesthetic complications.

If tumour resection was not required, IV anaesthesia and a natural airway was used. No complications occurred using this technique suggesting that it is safe in this high risk group of patients. Heliox (80% helium:20% oxygen) via facemask was administered if the patient had tracheal compression. A typical recipe was:

  1. Administer IV midazolam and glycopyrrolate
  2. Apply facemask with Heliox (80:20) if airway compression is present
  3. Prior to starting case, administer
    1. Dexmedetomidine 0.5-1 mcg/kg IV over 10 minutes
    2. 5 mg/kg IV
  4. During case, administer
    1. Dexmedetomidine 1 mcg/kg/hr IV
    2. Ketamine 1 mg/kg/hr IV and additional boluses as needed

 

The retrospective design, single centre and small patient numbers are the studies main limitations. During the study period, this institution developed a multi-disciplinary mediastinal mass huddle. Procedures required for the patient were identified to ensure they are done under one anaesthetic. The need for ventilation via a rigid bronchoscope is also discussed and anaesthesia tailored to individual patients.

Reviewed by Dr Vicky Lewis 

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