Presented at Egyptian Anesthesia 2011 @ MEDICONEX 2011

1. PROBLEM BASED LEARNING Dr Moataz Abdelrahman Consultant Paediatric Anaesthetist Central Manchester University Hospitals Royal Manchester Children’s Hospital

2. CASE 3 A 4 year old girl weighing 15.2 Kg is on your list for a lumbar puncture. She had a history of cough over the last 8 days which is non-productive, no history of asthma and her chest is clear to auscultation. With the start of the cough she was feverish 38.2 0C and suffered a brief seizure which resolved spontaneously. Temp is now 36.8 0C. CBC normal apart from mild leukocytosis. She had a GA last year for a cystoscopy which was uneventful. What is your approach?

3. WHAT TO DO Do the case today Explain your anaesthetic Precautions Safety Postpone Reasons for delay Valid You are to convince clinicians and parents What will you achieve?

6. MEDIASTINUM

7. CAUSES Tumours of the lung, mediastinum and pleura. Primary (uncommon) Metastatic The commonest Lymphoblastic lymphoma (non-Hodgkin’s lymphoma) Hodgkin’s disease. Other lesions Vascular malformations Neurogenic tumours Germ cell tumours Cysts (bronchogenic or enteric)

8. PRESENTATION No Cardio-respiratory symptoms Respiratory Cough, dyspnoea, stridor Cardiac Orthopnoea, syncope, Superior vena cava syndrome Swelling of the upper arms, face and neck General constitutional symptoms

9. COMPRESSION Trachea Bronchi Lungs Heart (RVOT) Pulmonary artery Superior vena cava

10. ALARMING S&S

11. PROBLEMS Respiratory collapse Cardiovascular collapse During Induction (mainly) Maintenance Recovery Relation to preoperative manifestation???

12. The incidence of cardio-respiratory complications is high (7-20% in adults) and higher in children Mortality in relation to general anaesthesia is high in children Asymptomatic children have suffered serious morbidity or even death whilst undergoing general anaesthesia

13. EVALUATION Symptoms Signs Investigations CT ECHO PFT ? if feasible PREDICTABILITY OF AIRWAY COLLAPSE/OBSTRUCTION AND CVS COMPROMISE

14. CARDIAC – echo, CT Pericardium Thickening Effusion RVOT LV function

15. AIRWAY - CT CXR Level of compression Degree of compression Type of lesion and extent Other lesions 30% occlusion  incidence of resp complications 50% occlusion  incidence of complete obstruction Static pictures may not identify dynamic compression

16. AIRWAY - PFT Difficult in children PEFR 50% of expected correlates with 50% central airway (trachea) obstruction 50% of expected PEF incidence of complete obstruction

17. ANAESTHETIC MANAGEMENT A clear strategy should be followed Multidisciplinary involvement Identify high risk patients The need for a general anaesthetic should be justified Local anaesthesia/sedation could be an alternative

19. ANAESTHETIC MANAGEMENT The objective is to minimise airway and cardiovascular compression Reduce the size of the tumour Preoperative steroids for 1-5 days Preoperative chemotherapy Preoperative Radiotherapy Secure tracheal/bronchial patency Maintain spontaneous breathing Avoid muscle relaxants If IPPV high pressures may be needed + PEEP? Stinting the trachea and main bronchi Use of 2 micro-laryngosurgery tubes?

21. ANAESTHETIC MANAGEMENT Inhalation technique recommended Rigid brochoscope should be available Bypass the obstruction Life saving Positioning Rt Lateral Prone Surgeon ready for sternotomy Immediate decompression Facilities should be available Cardiopulmonary bypass Sometimes not practical

22. CONCLUSION Children presenting for malignancy investigation (LP - BMA - LN Biopsy) should have a chest X-ray and any mediastinal mass detected need to be dealt with according to a specific protocol