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Case report
Anaesthetic management of an infant with
anterior mediastinal mass
LAKSHMI VAS, FALGUNI NAREGAL AND VEENA NAIK
Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel Bombay 400, India
Summary
A substantial mediastinal mass in a small infant can create a
dilemma regarding the safest mode of airway management. To
ensure safety at all times, we adopted one lung ventilation for fear
of compression of the carina and/or both main bronchi. Anaesthesia
was maintained at a very light plane by the use of local nerve
blocks to secure the airway and epidural analgesia for surgery until
the tumour was moblized.
Figure 1
Mediastinal mass occupying most of the right half of the chest.
Figure 3
Computed tomography showing
the mass compressing the
trachea.
gases with one lung ventilation. A 19-G Touhy needle 50 mmHg. The pH varied between 7.2 and 7.4, PCO2
(Portex Hythe, Kent) was introduced into the L3–4 5.32–8.22 kPa (40–61 mmHg), PO2 6.25–19.01 kPa
interspace to pass an open ended epidural catheter (47–140 mmHg) with 0.6–1 FiO2. Once the tumour
to the T5 level and 1.5 ml of 0.25% bupivacaine were was removed, the airway pressures could be reduced
injected. to 25–30 cmH2O. After surgery and reversal of
Anaesthesia was continued with halothane 1% in neuromuscular blockade, the oxygen and CO2 were
oxygen with intermittent assistance to spontaneous well maintained. The child appeared to be quite
ventilation. The chest was opened by median comfortable and pain-free but still had tachypnoea.
sternotomy and the whole tumour visualized. Only The armoured tracheal tube was left in situ overnight,
then was the patient paralysed with atracurium for because there was an anxiety that any postoperative
intermittent positive-pressure ventilation, the swelling around the airway could potentially occlude
endobronchial tube withdrawn into the trachea and it. He required sedation with midazolam 0.05.kg−1
both lungs ventilated. The SpO2, PeCO2 and intravenously to retain the tube and as the ventilation
electrocardiogram remained within normal limits. was adequate with normal blood gases in air, we
The time for induction of anaesthesia, placement of preferred to leave him breathing spontaneously in
various lines and epidural catheter until opening of 0.3 FiO2 rather than ventilate him which would entail
the chest was 65 min. After paralysis, the pressure paralysis and further sedation. Eighteen hours
necessary to maintain a tidal volume of 8 ml·kg−1 postoperatively, when his condition had stabilized,
required to be increased. During dissection, the with normal blood gas values, he was extubated.
airway pressure varied erratically, up to a high of Anti inflammatory agents diclofenac 1 mg·kg−1
80 cmH2O. On four occasions surgery had to be intramusculary initially and later nimusulide 5 mg
stopped temporarily to allow ventilation, with the twice daily via the Ryle’s tube and hydrocortisone
surgeon holding the tumour away from the trachea, were also given.
especially when the posterior aspect of the tumour He continued to receive epidural analgesia with
was being dissected. The tumour was found to be 1 ml of 0.125%. bupivacaine 6 hourly for 3 days. The
overlying a substantial segment of the left and right histopathology revealed the tumour to be a well
main bronchi. The blood loss of 450 ml was replaced differentiated teratoma. The patient is presently
with blood and 50 ml of fresh frozen plasma. The normal with no recurrence of the tumour 18 months
pulse varied between 130·min−1 and 150·min−1 and after surgery.
the direct systolic arterial pressure between 90 and
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