The Anesthetic Management of Anterior Mediastinal Masses in Children: A Review

Incidence, outcome and risk factors of perioperative pulmonary complications in pediatric patients with mediastinal mass

PURPOSE

This retrospective study was designed to identify the incidence, outcome and analyze risk factors of perioperative pulmonary complications in children with mediastinal mass so that to achieve the Enhanced Recovery After Surgery(ERAS).

METHODS

This study enrolled 247 pediatric patients undergoing mediastinal mass resection from June 2016 to June 2022. Medical record was reviewed for basic characteristics, presenting symptoms, preoperative imaging results, intraoperative data, and the occurrence of any pulmonary complications. Perioperative pulmonary complication was defined as intraoperative hypoxemia, postoperative respiratory failure, postoperative pulmonary infection or atelectasis. Univariate analysis and multivariate logistic regression were used to analyze the risk factors for perioperative pulmonary complications.

RESULTS

The incidence of perioperative pulmonary complications was 25.9% and postoperative pneumonia was most common. children with perioperative pulmonary complications had longer mechanical ventilation time (186.5 min), ICU stay (1.5d) and hospital stay (9d, all P < 0.001). After multivariable analysis, preoperative cardiopulmonary compression symptoms (OR 21.337, P < 0.001), malignant tumor (OR 2.681, P = 0.043), anterior mediastinum(OR 2.616, P = 0.037), standardized tumor volume ≥ 0.65(OR 3.607, P = 0.003), intraoperative transfusion(OR 1.991, P = 0.004), surgery time ≥ 150 min (OR 2.363, P = 0.056) were the risk factors for perioperative pulmonary complications.

CONCLUSIONS

Pulmonary complications were still common in children with mediastinal mass during or after surgery, which can influence the recovery after surgery with the prolonged mechanical ventilation time, ICU stay and hospital stay. Preoperative cardiopulmonary compression symptoms, malignant tumor, anterior mediastinum, standardized tumor volume ≥ 0.65, intraoperative transfusion and longer surgery time are associated with the occurance of perioperative pulmonary complications.

Development of clinical pathways to improve multidisciplinary care of high-risk pediatric oncology patients

Clinical pathways are evidence-based tools that have been integrated into many aspects of pediatric hospital medicine and have proven effective at reducing in-hospital complications from a variety of diseases. Adaptation of similar tools for specific, high-risk patient populations in pediatric oncology has been slower, in part due to patient complexities and variations in management strategies. There are few published studies of clinical pathways for pediatric oncology patients. Pediatric patients with a new diagnosis of leukemia or lymphoma often present with one or more “oncologic emergencies” that require urgent intervention and deliberate multidisciplinary care to prevent significant consequences. Here, we present two clinical pathways that have recently been developed using a multidisciplinary approach at a single institution, intended for the care of patients who present with hyperleukocytosis or an anterior mediastinal mass. These clinical care pathways have provided a critical framework for the immediate care of these patients who are often admitted to the pediatric intensive care unit for initial management. The goal of the pathways is to facilitate multidisciplinary collaborations, expedite diagnosis, and streamline timely treatment initiation. Standardizing the care of high-risk pediatric oncology patients will ultimately decrease morbidity and mortality associated with these diseases to increase the potential for excellent outcomes.

Anesthetic management of patients undergoing mediastinal mass operation

Objectives

To summarize the anesthetic management of patients undergoing mediastinal mass operation.

Methods

Electronic databases were searched to identify all case reports of patients undergoing mediastinal mass operation. Information such as clinical characteristics, perioperative management and patients’ outcomes were abstracted and analyzed.

Results

Seventy-seven case reports with 85 patients aging from 34 days to 81 years were included. Mediastinal masses were located in anterior (n = 48), superior (n = 15), middle (n = 9) and posterior (n = 9) mediastinum, respectively. Clinical manifestations included dyspnea (n = 45), cough (n = 29), chest or radiating pain (n = 12), swelling (n = 8), fever (n = 7) and chest distress (n = 4). Most patients (n = 75) had signs of compression or invasion of vital structures. General anesthesia (n = 76) was the most commonly used method of anesthesia. Muscle relaxants were administered in 35 patients during anesthesia induction and spontaneous respiration was maintained in 37 patients. Mediastinal mass syndrome (MMS) occurred in 39 cases. Extracorporeal circulation was utilized in 20 patients intraoperatively. Three patients experienced cardiac arrest after ventilation failure and two patients died intraoperatively and one postoperatively.

Conclusions

Peri-operative management of patients undergoing mediastinal mass operation could be challenging. Pre-operative multi-disciplinary discussion, well-planned anesthetic management and pre-determined protocols for emergency situations are all vital to patient safety.

Anesthesia for children with anterior mediastinal masses

Children with an anterior mediastinal mass may have cardiopulmonary compromise that can be exacerbated under general anesthesia. Signs and symptoms such as cough, shortness of breath, stridor, orthopnea, accessory muscle use, a history of respiratory arrest, and the presence of a pleural effusion and upper body edema are predictive of perioperative complications. A larger mediastinal mass on imaging is predictive of perioperative complications. Risk stratification of patients, together with an individualized plan, will best guide operative management for patients with an anterior mediastinal mass. General anesthesia (GA) should be avoided if possible, but a spontaneous breathing technique is recommended if GA is required.

Pediatric sudden unexpected death due to undiagnosed mediastinal T-cell lymphoblastic lymphoma: A series of three cases

The literature on pediatric sudden unexpected death (SUD) due to unrecognized mediastinal neoplasms is limited to a small number of case reports with several cases confirmed to be secondary to T-cell lymphoblastic lymphoma (T-cell LBL). Mediastinal T-cell LBL can be rapidly progressive and potentially fatal due to the compression and obstruction of the airway and/or the great vessels. The clinical presentation is nonspecific with a predominance of respiratory symptoms that are more apparent when the patient is supine. We presented three cases of pediatric SUD attributed to forensic autopsy-diagnosed anterior mediastinal T- cell LBL. Case 1 involved a 2-year-old girl who presented with 9 days of cough and dyspnea. Postmortem examination revealed a firm rubbery mass surrounding the heart and compressing the bronchi. Case 2 involved a 3-year-old girl who suffered from a respiratory tract infection over several days. Autopsy revealed a firm nodular mass compressing the superior vena cava. Case 3 involved a 2-year-old boy who was found unresponsive, lying prone in his crib. He had cold-like symptoms for several days before his death. Postmortem examination revealed a firm, rubbery anterior mediastinal neoplasm surrounding the superior vena cava and great arteries. These three cases demonstrate the importance of identifying children with mediastinal masses that could potentially lead to life-threatening presentations and pediatric SUD. The forensic pathologist should consider a hematologic neoplasm at the time of autopsy in a previously healthy child who dies suddenly.