Anaesthesia for patients with mediastinal masses

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, Nov 1989

Anaesthesia for patients with mediastinal masses may be associated with significant respiratory and cardiovascular complications. In this review, we discuss the anatomical and pathological considerations in these adult and paediatric patients and the three types of intra-thoracic compromise that may be found: compression of the tracheobroncheal tree, compression of the pulmonary artery and heart and the superior vena caval syndrome. Patient evaluation by symptom history, computerized tomography and flow-volume loops is emphasized. Preoperative thoracic radiation therapy in severely symptomatic patients is associated with a decrease in postoperative respiratory complications and an improvement in risk. During radiation therapy a small window can be created to spare some tissue for adequate histological diagnosis. Anaesthetic management techniques for these patients are discussed. Life-threatening complications can occur at any point during anaesthesia for patients with mediastinal masses. Anaesthetists should have a high degree of awareness of the underlying anatomy, pathophysiology and anaesthetic alternatives when caring for these patients.

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Anaesthesia for patients with mediastinal masses

J. Pullerits FRCPC 0 R. Holzman 0 0 Department of Anesthesia, The Children's Hospital and the Department of Anaesthesia, Harvard Medical School , Boston, Massachusetts , U.S. A. Anesthesia , The Children's Hospital , 300 Longwood Avenue, Boston, Massachusetts, USA 02115 Anaesthesia for patients with mediastinal masses may be associated with significant respiratory and cardiovascular complications. In this review, we discuss the anatomical and pathological considerations in these adult and paediatric patients and the three types of intra-thoracic compromise that may be found: compression of the tracheobronchial tree, compression of thepulmonary artery and heart and the superior vena caval syndrome. Patient evaluation by symptom history, computerized tomography and flow.volume loops is emphasized. Preoperative thoracic radiation therapy in severely symptomatic patiems is associated with a decrease in postoperative respiratory complications and an improvement in risk. During radiation therapy a small window can be created to spore some tissue for adequate histological diagnosis. Anaesthetic management techniques for these patients are discussed. Life-threatening complications can occur at any point during anaesthesia for patients with mediastinol masses. Anaesthetists should have a high degree of awareness of the underlying anatomy, pathophysiology and anaesthetic alternatives when caring for these patients. - Patients with mediastinal masses may require anaesthesia for incisional or excisional biopsy, staging laparotomy and a variety of additional procedures during their course of treatment. A large mediastinal tumour, due to its mass effects, may be associated with dramatic cardiopulmonary complications including progressive airway obstruction, loss of lung volume, pulmonary artery or cardiac compression and superior vena caval obstruction, i Each of these complications can cause death during anaesthesia if not expertly handled. Providing safe anaesthesia for these patients requires an understanding of the anatomy of the region, the pathophysiology of the lesions and an appreciation of their compressive effects on vital intrathoracic structures. This review discusses the anatomy of the region, the pathology and the clinical presentations of the mediastinal lesions themselves. The preoperative evaluation and preparation of these patients is discussed, stressing the need for a thorough CT evaluation of the entire thorax. In the discussion on the anaesthetic management, we have stressed that even asymptomatic patients with mediastinal masses have the potential to develop catastrophic airway obstruction. Anatomy The mediastinum is that portion of the thorax lying between the fight and left pleural sacs. It is bounded anteriorly by the sternum and by the bodies of the thoracic vertebrae posteriorly and extends from the thoracic inlet superiorly to the diaphragm inferiorly. The mediastinum is divided into superior and inferior regions by a plane extending from the sternal angle to the lower border of the fourth thoracic vertebra. The upper region is named the superior mediastinum and the lower region, the inferior mediastinum. The inferior mediastinum is, in turn, divided into the anterior, middle and posterior mediastina by the pericardium. Anatomical structures of major importance to the anaesthetist are found at the junction of the superior, anterior, middle and posterior mediastina. These structures include the superior vena cava, the tracheal bifurcation, the main pulmonary artery, the aortic arch and part of the superior surface of the heart. FIGURE 1 Turnoutsof the mediastinum.Reproduced,withpermission,fromthe Cibacollectionof medicalillustrationsby FrankG. NetterMD. Pathology Although specific tumours have a predilection for particular regions of the mediastinum, many kinds of tumours have been reported in the various mediastinal regions (Figure 1). In adults, thymomas account for a large proportion of anterior mediastinal tumours, with a 50 per cent malignancy rate and a 50 per cent association with a myasthenia gravis symptomatology. Thyroid tumours may extend below the sternum and present as anterior mediastinal masses, as may teratomas in their benign as well as malignant forms. Lymphoid tumours usually occur in the anterior or middle mediastinum. Ninety per cent of lymph node masses in the middle mediastinum are malignant as a result of metastatic spread. Other masses in the middle mediastinum include those of vascular origin (aneurysms), oesophagus (achalasia, diverticula) or cysts (bronchogenic, pericardial). Masses of the posterior mediastinum are usually of neurogenic origin (neurofibromas, Schwannomas and benign ganglioneuromas arising from the sympathetic chain). In children, tumours of the mediastinum are most often bronchial cysts, teratomas, or lymphomas. In a series of 188 children, the majority of malignant tumours were Hodgkin's and non-Hodgkin's lymphomas of the anterior and midd (...truncated)


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J. Pullerits, R. Holzman. Anaesthesia for patients with mediastinal masses, Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 1989, pp. 681-688, Volume 36, Issue 6, DOI: 10.1007/BF03005421