Paediatric Mediastinal Mass

• Hodgkin lymphoma
• Non-Hodgkin lymphoma
• Acute lymphoblastic leukaemia
• Germ cell tumours
• Vascular malformations
• Teratomas
• Neurogenic tumours

• Anaesthetics
• Intensive care
• ENT
• Paediatric surgeons
• Cardiothoracics
• Oncology
• Patient and family

Aside from your usual anaesthetic history to determine their baseline anaesthetic risk, you want to explore their symptoms that might suggest significant intrathoracic airway or SVC compression.

• Cough when supine
• Orthopnoea
• Stridor
• Wheeze
• Syncope
• Upper body oedema

CT is imaging modality of choice. You'll probably already have a chest xray as well.

• This can be tricky in a child that doesn't want to lie flat or still
• Might need to be lateral or prone
• Tracheal compression of >70% is high risk
• Pericardial effusion and great vessel compression also indicate high risk

Echocardiography can also be used to assess effusions, compression and ventricular function.

Spirometry is of variable use in demonstrating airway obstruction.

• Keep the patient spontaneously breathing
• Ideally have IV access already in case you lose the airway during induction
• Sevoflurane inhalational induction
• Avoid nitrous - bone marrow suppression
• Avoid muscle relaxants - they reduce chest wall tone and predispose to airway collapse
• Be on the lookout for tumour lysis syndrome - check with oncology whether dexamethasone is appropriate
• Might be a good time to put a Hickman or equivalent in, as this kid is going to need long term IV access
• Glycopyrrolate to treat secretions from ketamine
• Midazolam to offset the bonkers from ketamine
• Wide awake extubation

• Positioning - head up, lateral, prone - depending on child's comfort*
• Blood loss - discuss transfusion beforehand, lots of IV access
• Airway management
• Duration of procedure

*Ask the child what position is most comfortable to lie in, so you know what position to move them into if you lose the airway - see below.

Good luck doing anything with a distressed child awake under local anaesthesia, especially one with an obstructed airway who can't lie flat.

You can add in sedation:

• Ketamine - 1-2mg/kg then 0.5 mg/kg as required
• Dexmedetomidine - 1mcg/kg then 0.25-2mcg/kg/hour infusion

These maintain respiratory drive and cardiovascular tone while providing good analgesia and decent sedation.

The appropriateness of sedation and local as a plan is going to depend on the child and the procedure. It works well in a compliant slightly older child for a short peripheral biopsy.

Aside from your usual causes of haemodynamic compromise in an anaesthetised child, there's the added risk of compression-induced complete loss of right ventricular preload.

Things you can try:

• IV fluids
• Lighten anaesthesia
• Prone position
• Sternotomy to relieve the pressure*

*Please don't sternotomise a child by yourself, let someone with some surgical qualifications do it.

One can always try ECMO, however how much use it ends up being is debatable.

The two main issues neatly summed up are:

• Trying to pre-emptively cannulate an unsedated child is less than fun
• It takes too long to do it in an emergency