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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Discretion is the better part of valour: Non-operating room anaesthesia for tissue diagnosis of a mediastinal mass

 Department of Paediatric Anaesthesia, NH-SRCC Children's Hospital, Mumbai, Maharashtra, India

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Date of Submission16-Feb-2022
Date of Acceptance08-Apr-2022
Date of Web Publication27-May-2022

How to cite this URL:
Karnik PP, Dave NM, Rawlani SS, Dhabe VV. Discretion is the better part of valour: Non-operating room anaesthesia for tissue diagnosis of a mediastinal mass. Airway [Epub ahead of print] [cited 2022 Sep 28]. Available from: https://www.arwy.org/preprintarticle.asp?id=346191

Non-operating room anaesthesia (NORA) in a case of mediastinal mass with respiratory symptoms can be challenging. We averted a possible adverse event in a 2-year-old child with anterior mediastinal mass by deferring anaesthesia during the decompensated phase and planning anaesthesia after partial resolution of symptoms following chemotherapy based on possible clinical diagnosis. This decision was jointly taken after obtaining consent of the parents.

A 2-year-old child weighing 13 kg had a history of fever on and off with subcostal retraction and inability to lie supine for 2 months. Computed tomography (CT) scan showed a middle mediastinal mass measuring 6 cm × 6 cm × 5 cm causing 50% compression of both mainstem bronchi, right more than the left [Figure 1]a. On presentation, the child was tachypnoeic, irritable, unable to lie supine and needed oxygen by nasal prongs. The child was tentatively posted for CT-guided biopsy of the mass.
Figure 1: Computed tomography scan of the chest showing compression of both main bronchi by mass a) pre-chemotherapy and b) an improved airway post-chemotherapy

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Administering anaesthesia in a decompensated clinical situation could have entailed loss of airway not amenable to the use of rigid bronchoscope as compression was below the level of the carina involving both main stem bronchi. Preservation of spontaneous respiration and maintenance of airway, prone positioning and providing an adequate level of anaesthesia would have been a tightrope walk. Hence, we deferred the CT-guided biopsy and the child underwent bone marrow biopsy to rule out lymphoma. Although the bone marrow biopsy was inconclusive, the child was given a cycle of chemotherapy with vincristine and cyclophosphamide since the clinical picture resembled that of lymphoma. The medical oncologist discussed the treatment plan with the parents and took written informed consent before the cycle of chemotherapy. Parents were counselled and explained the importance of regression of mass size for tissue biopsy. There was considerable improvement in symptoms in the week following chemotherapy with the child now able to lie supine without respiratory distress and oxygen requirement. CT-guided biopsy was then planned to corroborate the diagnosis.

The difficult airway cart with small-sized endotracheal tubes, Frova intubating introducer and jet insufflator were kept ready. As the symptoms had decreased, presence of the otorhinolaryngology team and rigid bronchoscopy standby were not considered mandatory. We started injection dexmedetomidine 1 μg/kg as a slow intravenous (IV) bolus over 10 min followed by continuous infusion at 0.3 μg/kg/h. Midazolam 1 mg and fentanyl 15 μg were given intravenously and oxygen was administered via nasal prongs at 2 litres per minute. CT scan showed a significant reduction in the size of the mass and an improved airway calibre [Figure 1]b. The child was placed in the prone position after administering IV ketamine 10 mg. The biopsy needle had to be passed through the lung parenchyma to reach the mass as it had considerably shrunk in size following chemotherapy. Although the postprocedure CT scan did not show any collection or significant injury to the lung parenchyma, the child was shifted to the paediatric intensive care unit to watch for delayed pneumothorax or haemothorax.

Anaesthesia in the presence of a large mediastinal mass in children can cause total loss of the airway and cardiovascular collapse with 7%–18% chance of airway-related complications.[1] Cardiopulmonary bypass (CPB) may be the only option to salvage such patients.[2] However, CPB standby is not possible in the setting of NORA. In our case, we deferred anaesthesia due to warning signs of decompensation such as subcostal retraction, oxygen dependence, inability to lie supine and imaging studies showing significant bronchial compression. Even after resolution of symptoms following chemotherapy, we used agents such as dexmedetomidine and ketamine for sedation which cause minimal static or dynamic changes of the paediatric airway.[3],[4] Should airway obstruction develop, positioning the child lateral or prone to shift the mass off the airway, rigid bronchoscope and jet ventilation include potential management techniques. It is essential to exercise caution in such situations, question the necessity of risky procedures and find suitable alternatives for therapy.[5],[6] Brainstorming within the team helped us reach a logical course of action in a compromised airway.


I would like to extend my gratitude to all my colleagues for their support to successfully manage the anaesthetic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Thakur P, Bhatia P, Sitalakshmi N, Virmani P. Anaesthesia for mediastinal mass. Indian J Anaesth 2014;58:215-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
Corridore M, Phillips A, Rabe AJ, Tobias JD. Dexmedetomidine-ketamine sedation in a child with a mediastinal mass. World J Pediatr Congenit Heart Surg 2012;3:142-6.  Back to cited text no. 2
Mahmoud M, Radhakrishman R, Gunter J, Sadhasivam S, Schapiro A, McAuliffe J, et al. Effect of increasing depth of dexmedetomidine anesthesia on upper airway morphology in children. Paediatr Anaesth 2010;20:506-15.  Back to cited text no. 3
Carollo DS, Pestieau S, Bosco R. Dexmedetomidine for anterior mediastinal mass computed tomography-guided biopsy: A case series. Ochsner J 2013;13:541-3.  Back to cited text no. 4
Hack HA, Wright NB, Wynn RF. The anaesthetic management of children with anterior mediastinal masses. Anaesthesia 2008;63:837-46.  Back to cited text no. 5
Culshaw V, Yule M, Lawson R. Considerations for anaesthesia in children with haematological malignancy undergoing short procedures. Paediatr Anaesth 2003;13:375-83.  Back to cited text no. 6

Correspondence Address:
Sujata Shivlal Rawlani,
Flat No. 8, Hind Mansion, Sitladevi Temple Road, Opposite Kolhapur Dairy, Mahim, Mumbai - 400 016, Maharashtra
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Source of Support: None, Conflict of Interest: None


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