Rescue of cardiopulmonary collapse in anterior mediastinal tumor: case presentation and review of literature

Perioperative Extracorporeal Cardiopulmonary Resuscitation in Adult Patients: A Review for the Perioperative Physician

The use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest has grown rapidly over the previous decade. Considerations for the implementation and management of extracorporeal cardiopulmonary resuscitation are presented for the perioperative physician.

Timely diagnostics and safe procedures in children with anterior mediastinal masses (AMMs): a qualitative review of the AMM protocol at BC Children's Hospital in Vancouver BC

The presence of an anterior mediastinal mass should prompt rapid triage, workup and treatment to effectively manage and prevent emergent complications. Implementation of an AMM protocol can ensure the response is standardized and coordinated. Importantly, such a protocol can encourage prompt multi-disciplinary communication to mitigate risks associated with procedures required for timely diagnosis. The aim of this review is to evaluate the BC Children's Hospital's Pediatric New/Suspected Anterior Mediastinal Mass (AMM) Protocol. Retrospective chart review was conducted for 18 patients admitted from February 2016 to May 2020 with AMM for whom the protocol was enacted. Primary parameters assessed presence of high-risk feature at time of presentation, time from admission and/or protocol activation to specific time points, including imaging, first diagnostic procedure, and diagnosis. Data regarding perioperative management, including anesthetic considerations and peri-operative complications, was also collected. Mean time from protocol activation to first diagnostic procedure and diagnosis were 1.88 days (range 0-7) and 2.24 days (range 0-7), respectively. The majority of procedures were conducted under sedation (n = 77, 64%), followed by general anesthetic (GA; n = 34, 28%) and local anesthetic (n = 10, 8%). Despite 15 cases having more than one high risk feature, pre-operative steroids were only administered for four of the total 158 procedures (3%) and extracorporeal life support (ECLS) and otolaryngology (ENT) were only required for immediate availability for seven procedures (4%). Furthermore, only 10 procedures (8%) had associated complications and none of these complications resulted in patient death. Our data demonstrate that implementation of a streamlined multi-disciplinary protocol can expedite time to diagnosis without impacting patient safety.

Airway Emergencies Due to Anterior Mediastinal T-Lymphoblastic Lymphoma Managed With Planned Extracorporeal Membrane Oxygenation and Endotracheal Stent: A Case Report and Literature Review

Anterior mediastinal tumors can occasionally cause acute respiratory failure by compressing the trachea and bronchi. In such cases, sedative muscle relaxants during tracheal intubation can cause fatal complete tracheal obstruction. We encountered a 15-year-old male patient with T-lymphoblastic lymphoma (T-LBL) of the anterior mediastinum. For his airway emergency due to the stenosis extended from the lower part of the trachea to the tracheal bifurcation, venovenous (VV) extracorporeal membrane oxygenation (ECMO) was introduced from the femoral vein under local anesthesia. After a short period of tracheal intubation management, an endotracheal stent (ES) was immediately placed in the lower trachea. We performed a needle biopsy, and he was diagnosed with T-LBL. Following the diagnosis, chemotherapy was introduced. The ES was able to secure sufficient tracheal diameter, and ECMO and ventilation were promptly discontinued. In the case of tracheal stenosis from the lower part of the trachea due to anterior mediastinal tumor, depending on the degree of stenosis, VV ECMO can be considered. Moreover, ES can lead to early weaning from VV ECMO and a ventilator.

Updates and controversies in anesthesia for advanced interventional pulmonology procedures

PURPOSE OF REVIEW

Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved.

RECENT FINDINGS

We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine.

SUMMARY

The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.

Extracorporeal Membrane Oxygenation Support in Children With Hematologic Malignancies in Sweden

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is used in severe respiratory and/or circulatory failure when conventional critical care fails. Studies on patients with hematologic malignancies on ECMO have shown contradictory results; immunosuppression and coagulopathy are relative contraindications to ECMO.

OBSERVATIONS

This nationwide Swedish retrospective chart review identified 958 children with hematologic malignancies of whom 12 (1.3%) required ECMO support. Eight patients survived ECMO, 7 the total intensive care period, and 6 survived the underlying malignancy.

CONCLUSIONS

ECMO may be considered in children with hematologic malignancy. Short-term and long-term survival, in this limited group, was similar to that of children on ECMO at large.

Young Man with Cardiac Arrest Secondary to Undiagnosed Mediastinal Mass: A Case Report

INTRODUCTION

A 20-year-old man with a reported history of asthma presented to the emergency department in cardiac arrest presumed to be caused by respiratory failure.

CASE REPORT

The patient was discovered to have central airway obstruction and concomitant superior vena cava compression caused by a large mediastinal mass-a condition termed mediastinal mass syndrome. While the patient regained spontaneous circulation after endotracheal intubation, he was challenging to ventilate requiring escalating interventions to maintain adequate ventilation.

CONCLUSION

We describe complications of mediastinal mass syndrome and an approach to resuscitation, including ventilator adjustments, patient repositioning, double-lumen endotracheal tubes, specialty consultation, and extracorporeal life support.

ECMO and adult mediastinal masses

The role of extracorporeal membrane oxygenation (ECMO) is expanding as surgeons look at its utility beyond rescue treatment and have started adopting it for high-risk procedures to provide temporary airway and hemodynamic stabilization. ECMO needs to be deliberated in all patients with mediastinal masses who have compromised airways as well as in those with compression of heart and great vessels. There is a dearth of literature highlighting the definitive role of ECMO in patients with mediastinal masses. This article reviews the available adult literature and highlights the possible situations where the use of ECMO would be supportive in the management of patients with mediastinal masses.

Clinical manifestation of pediatric mediastinal tumors, a single center experience

Medical decisions should be well-planned to improve prognosis and reduce complications of mediastinal tumors. In this study, we analyzed the clinical presentations of pediatric mediastinal tumors and their correlation with long-term clinical outcome.Forty patients under 18 years of age diagnosed with mediastinal tumors at China Medical University Children's Hospital between 2001 and 2016 were enrolled. The patients' sex, age of onset, initial clinical symptoms, and treatment outcomes were analyzed.75% of the patients with mediastinal tumors in this study were men, and the median age of onset was 13 years old (age range: 0-17 years). The overall mortality rate was 40%. The most common tumors were lymphoma (47.5%), followed by germ cell tumors (12.5%), neuroblastoma (12.5%), and thymoma (7.5%). Neuroblastoma was more prevalent in girls younger than 5 years old. The initial presentations of these patients included breathing difficulty (65%), productive cough (47.5%), pleural effusion (54.5%), superior vena cava (SVC) syndrome (35%), neck mass (35%), airway compression (32.5%), fever (30%), chest pain (27.5%), and pericardial effusion (25%). Lymphomas were more likely to be accompanied by neck mass (52.6% vs19.0%, P = .04) and SVC syndrome (52.6% vs 19.0%, P = .026), yet also had a better 1-year-survival rate (68.4% vs 52.4%, P = .02).Overall, lymphoma should be suspected when children present with neck mass and SVC syndrome. Neuroblastoma with a posterior mediastinal origin should be suspected among children younger than 5 years old. Tumor-related airway obstruction, pleural effusion, and pericardial effusion were leading cause of cardiopulmonary instability during sedation for invasive procedures, which should be managed cautiously.

Perioperative management of an anterior mediastinal teratoma in an infant: one more tool in the toolbox

Anterior mediastinal masses present a significant challenge in the perioperative period. Standard anaesthetic induction and airway management are often not feasible due to the risk of complete respiratory and/or cardiovascular collapse. Invasive manoeuvres, such as extracorporeal membrane oxygenation, cardiac bypass, or tracheal or bronchial stenting, are sometimes not applicable due to significant anatomic aberration. We present a case of anterior mediastinal mass in a 5-month-old infant where typical management techniques in the treatment algorithm were not possible.

VV-ECMO-Assisted High-Risk Endobronchial Stenting as Rescue for Asphyxiating Mediastinal Mass

The use of venovenous extracorporeal membrane oxygenation (VV-ECMO) has traditionally been limited to a narrow set of clinical circumstances, such as acute hypoxic respiratory failure, submassive pulmonary embolism, and cardiopulmonary collapse. Within the pediatric population, there have been cases of VV-ECMO in the context of extrinsic airway compression by a mediastinal mass, typically in the setting of either a lymphoma or germ cell tumors. However, the use of VV-ECMO for adults with extrinsic airway compression is comparatively limited. More specifically, VV-ECMO has been used as a bridge for tracheal reconstruction in both children and adults. Although, it has not been used in adults in the context of palliative endobronchial stent placement. We present a case of a 49-year-old woman with refractory multiple myeloma and extramedullary plasmacytoma presenting with acute hypoxic respiratory failure from extrinsic airway compression by a mediastinal plasmacytoma. We were able to use VV-ECMO to assist with endobronchial stent placement, followed by radiation therapy, and ultimately hospital discharge. In this article, we also review the literature surrounding VV-ECMO for extrinsic airway compression.

Surgical palliation of previously resected thoracic sarcoma

Surgical palliation can improve quality of life, provide local control, and extend survival. However, oncologists often view surgical intervention as a drastic measure with prohibitive morbidity. During the past decade, surgical palliation has played a role in the management of many metastatic malignancies, including those of the colon, breast, prostate, and kidney. In concert with this, the morbidity and mortality associated with surgical interventions has continued to decline. We present 2 patients with thoracic sarcoma recurrences after pneumonectomy that were associated with symptomatic compression of pulmonary vessels and airway. Both patients underwent surgical resection, with immediate relief of symptoms, improved quality of life, and extended survival.