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IN THE NAME OF GOD

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Clinical and diagnostic imaging findings predict anesthetic complications in children presenting with malignant

mediastinal masses

DORALINA L. ANGHELESCU, LAURA L. BURGOYNE BM, TIEBIN LIU,CHIN-SHANG LI, CHING-HON PUI, MELISSA M. HUDSON, WAYNE L. FURMAN, JOHN T. SANDLUND

Pediatric Anesthesia ,Volume 17

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Background: The presence of a mediastinal mass in a child poses significant anesthesia-related risks including death. To optimize outcome clinicians must be able to predict which patients are at highest risk of anesthetic complications.

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IntroductionThe presence of a mediastinal mass remains one of the most concerning features in the assessment of a child referred for anesthesia or sedation, because of the potential for life-threatening events under anesthesia.Controversy persists regarding the optimal diagnostic and therapeutic approach in children with a mediastinal mass, and whether anesthesia should be avoided in patients at especially high risk of respiratory compromise .Treatment with radiotherapy or chemotherapy prior to tissue diagnosis has been advocated ,but this approach may compromise the accuracy of the histopathological diagnosis .To proceed in an optimal manner in each case, clinicians must be able to predict which patients are at highest risk of anesthetic complications. In this study, we evaluated specific preoperative clinical and diagnostic imaging features and their association with adverse anesthetic outcomes in pediatric oncology patients presenting with a mediastinal mass.

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Medical records reviewThe interpretation of the chest radiograph at diagnosis was reviewed to establish the mediastinal mass to chest diameter ratio (MMR). The report of the computed tomography (CT) scan of the chest at the time of diagnosis was reviewed to evaluate the location of the mass within the mediastinum, compression of the trachea, carina and mainstem bronchi and to determine whether there was any cardiac or great vessel involvement by the tumor. The preoperative echocardiogram was assessed for pericardial, cardiac and great vessel involvement. The records were also examined to identify patients who experienced perioperative complications when the first two anesthetics were administered.

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Table 1.  Demographic characteristics of pediatric patients with a mediastinal mass at presentation (n = 118)

Characteristic n (%)

Race

 Black 18 (15.3)

 White 97 (82.2)

 Other 3 (2.5)

sex

 Female 45 (38.1)

 Male 73 (61.9)

Primary diagnosis

 Acute lymphoblastic leukemia 12 (10.2)

 Hodgkin lymphoma 45 (38.1)

 Non-Hodgkin lymphoma 37 (31.4)

 Solid tumor 24 (20.3)

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Although we examined the effects of as many as two anesthetics for each patient, all complications occurred during administration of the first anesthetic; no patient experienced a second complication. The surgical procedures associated with anesthetic complications included: cervical lymph node biopsy (n = 1), mediastinal mass biopsy (n = 2), central venous line placement (n = 1) and bone marrow aspiration and biopsy (n = 6). One patient had multiple procedures(Table 2).

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Table 2.  Anesthetic complications

Case No. Age (years) Sex Weight (kg)Primary diagnosis

Procedure AnestheticsComplication and notes

Treatment

  1 22 F 100 HLInsertion of central line

Midazolam and fentanyl

Oxygen desaturation

Unplanned intubation. Naloxone reversal. Extubated after 10 min.

 

  2 19 F 55 HLBM aspiration and biopsy

Propofol and fentanyl

Oxygen desaturation to 85%

Recovered without intervention

 

  3 10 M 31 T-cell ALL BM aspirationPropofol and lidocaine infiltration

PMH of asthma Coughing and wheezing Oxygen desaturation to 95%

Nebulized albuterol

 

  4 5 F 19 T-cell ALL BM aspirationPropofol and EMLA®

Anesthetized in sitting position Oxygen desaturation to 79%

Suctioned, manually ventilated. Procedure recommenced in left lateral position.

 

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5 6 M 23 NHLBM aspiration and biopsy

Propofol

PMH of asthma Oxygen desaturation to 70%

Manually ventilated

6 17 F 76 RMS BM aspiration Fentanyl

Large mediastinal mass Intubated in ICU prior to sedation

Apnea requiring change in ventilator settings

7 6 M 27 T-cell ALL

Insertion of central line, BM aspiration, and LP

Midazolam and ketamine

Oxygen desaturation to 86% Vomiting

Placed in lateral position, suctioned, face mask oxygen applied

8 12 F 46 T-cell ALL BM aspiration

Fentanyl, propofol, and lidocaine infiltration

Oxygen desaturation to 92% shallow respirations and substernal retraction

Recovered without intervention

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9 9 M 55 NHLPercutaneous mediastinal mass biopsy

Midazolam, fentanyl, and vecuronium

Intubated and difficult to ventilate preoperatively Oxygen desaturation to 79% and difficult to ventilate

On norepinephrine infusion and heliox Manually ventilated

10 13 F 43 NHLPercutaneous mediastinal mass biopsy

Fentanyl, propofol, and sevoflurane

Coughing and oxygen desaturation during propofol infusion. Anxiety and oxygen desaturation with emergence whilst supine

Changed to inhalation anesthesia Resolved with sitting position

11 16 M 85 T-cell ALLCervical lymph node biopsy

Midazolam, fentanyl, and nitrous oxide

Airway obstruction Oxygen desaturation to 50%

Intubated and changed to sitting position; oxygenation 90–100% Extubated after reversal with naloxone and flumazenil

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Complications occurred under various types of anesthesia: four events occurred under intravenous sedation (combinations of midazolam, fentanyl, and ketamine), six under propofol-based total intravenous anesthesia, and one under combined intravenous sedation and nitrous oxide anesthesia. Eleven patients had respiratory complications. Seven patients had minor or transient respiratory problems that responded to airway suctioning, manual ventilation via mask, or change in position to sitting or lateral decubitus. Two patients who were already intubated in the intensive care unit before surgery required an unexpected change in ventilatory strategy during anesthesia. Two patients required unplanned short-term intubation and opioid reversal to treat respiratory compromise.

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Four preoperative features were significantly associated with anesthetic complications: orthopnea (P = 0.033), upper body edema (P = 0.035), great vessel compression (P = 0.037), and main-stem bronchus compression (P = 0.044). Two other diagnostic imaging features demonstrated a trend toward a significant relation to anesthesia complications: pleural effusion (P = 0.060) and tracheal compression (P = 0.061) .Patients who had no complications had a smaller median MMR (0.37) than did those with anesthesia complications (0.45), although the difference between these values was not significant (P = 0.35). We found a relationship between the risk of anesthetic complications and the primary diagnosis of T-cell acute lymphoblastic leukemia (P = 0.002).

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Discussion:Although comparison of perioperative event rates is limited by variable study methods and definitions, our findings concur with those of four previous retrospective pediatric studies. The most recent study found a 15% rate of serious complications of general anesthesia in children with mediastinal tumors .In 45 children with lymphoma who underwent general anesthesia or local anesthesia with sedation, 11% experienced intraoperative complications and 6.7% had postoperative complications .In another study of 44 children with mediastinal masses who underwent general anesthesia, 18% experienced major perioperative cardiorespiratory events .Investigators in a study excluding patients whose tracheal cross-sectional area was less than half the predicted value found no complications in 42 patients with mediastinal masses. 1389/7/19

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1.Age at diagnosis: The only reported direct comparison of the incidence of complications in adults and children found that although adults and children experienced the same overall morbidity and mortality, all deaths of pediatric patients were caused by intraoperative airway complications .2.Primary diagnosis: We found a significant relationship between the risk of anesthetic complications and the primary diagnosis of T-cell acute lymphoblastic leukemia (P = 0.002). A recent adult study found no correlation between diagnosis and anesthetic risk ,while an earlier study in children with mediastinal lymphoma, revealed that only those with non-Hodgkin lymphoma had intraoperative complications. 3.Clinical presentation: Orthopnea and upper-body edema were associated with anesthetic complications in our study. In the most recent comparable study of adults, perioperative complications were predicted by cardiorespiratory symptoms .1389/7/19

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Anesthesia-related death and life-threatening airway obstruction have been reported in the absence of preoperative respiratory symptoms ;however, in those cases, either no preoperative CT studies were performed or imaging demonstrated airway obstruction or a large mass .One report described 20 children who had neither respiratory symptoms nor imaging evidence of tracheobronchial compression; all underwent general anesthesia without problems.4. Preoperative superior vena cava syndrome. In our study, upper body edema, a feature of SVC syndrome, was associated with anesthesia-related complications. Other reported case series on SVC syndrome have not systematically reviewed anesthetic outcomes .One such report from our institution described no anesthetic morbidity or mortality in 24 children with SVC obstruction and a mediastinal mass when tissue specimens were obtained by the least invasive feasible method.1389/7/19

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5. Tracheal cross-sectional area. We found an association between mainstem bronchus compression and the risk of anesthetic complications, although we did not quantify the extent of compression as others have performed. tracheal compression was the strongest predictor of complications of general anesthesia in the most recent pediatric series.6.Mediastinal mass ratio. The MMR is used to define small (MMR <0.3), medium MMR (0.31–0.44), and large (MMR >0.45) mediastinal masses .In our study, we found that patients who had complications had a larger median MMR than those who did not, although this difference was not statistically significant. Three other studies found a relationship between large MMR and perioperative complications.

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7. Perioperative involvement of major blood vessels or heart. We found that CT evidence of great vessel compression, but not of cardiac involvement, were significantly predictive of anesthetic complications. A number of case reports have also raised awareness of the significant risks of anesthesia in patients with cardiac encasement or great-vessel obstruction

8. Pleural effusion showed a trend toward statistical significance in our study. Consistent with this, in combination with three or more respiratory symptoms and signs, pleural effusion has been reported to be associated with anesthetic complications

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9.Preoperative radiotherapy and chemotherapy. None of the patients in our series received radiotherapy or empiric chemotherapy before anesthesia; however, we do not discount the possibility that some patients will be optimally managed using prediagnostic radiotherapy. Although prebiopsy radiotherapy and even chemotherapy have been advocated by some investigators to reduce the size of the mass and therefore the risks of anesthesia ,others have cautioned that these interventions distort tissue, thereby compromising the accuracy of diagnosis and curative treatment.

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10. Anesthesia technique. Recommendations regarding anesthetic technique in patients with mediastinal masses include maintenance of spontaneous ventilation, avoidance of muscle relaxants and the immediate availability of various airway manipulation techniques (reinforced tracheal tubes, mainstem bronchus intubation, rigid bronchoscopy, use of heliox and position adjustment) .In extreme cases, the use of cardiopulmonary bypass has been recommended .

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Our current practice reflects the following principles: (i) Preoperative evaluation involving multidisciplinary consultation between the oncologist, anesthesiologist, interventional radiologist, surgeon and radiation therapist; (ii) Careful choice of the least invasive method available to obtain a diagnostic sample, allowing minimal sedation or anesthesia; (iii) Maintenance of spontaneous respiratory effort is critical to avoid the risk of airway collapse in conjunction with positive pressure ventilation and muscle relaxation; (iv) Immediate availability of personnel and equipment for emergency airway management including rigid bronchoscopy and tracheostomy and consideration of cardiopulmonary bypass.

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In conclusion, orthopnea, upper-body edema, main-stem bronchus compression, and great vessel compression predicted anesthetic complications in pediatric patients who presented with mediastinal masses. The overall rate of complications was comparable with previous reports, but the events were less severe.

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We attribute this finding to a combination of factors, including:1.use of the least invasive method of obtaining tissue for diagnosis;2. availability of the technical means to obtain tissue by interventional radiology rather than major surgery; and 3.application of good anesthesia practices, especially a thorough preoperative assessment and the use of minimal anesthetic intervention. These strategies are recommended to minimize the incidence and severity of anesthetic complications in patients with mediastinal masses.

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