Feedback in the Clinical Setting with Jamie Rubin, MD
April 2025: Pediatric Anesthesiology Internet-Based Non-Technical Skills
Obesity & Anesthesia
Spring 2025 episode of OA-SPA Pediatric Anesthesia Virtual Grand Rounds
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Question of the Day
A 66-year-old, 100 kg man is to undergo a thoracotomy for excision of a 6x8 cm anterior mediastinal mass. The patient complains of orthopnea and a cough that is worse while lying flat. Physical exam reveals rhonchi in the right upper lung field. Imaging suggests mild tracheal compression. An awake intubation using fiberoptic bronchoscopy in a sitting position is planned, but inadequate local anesthetic is used to appropriately anesthetize the airway. The patient violently coughs during fiberoptic bronchoscopy, and then becomes anxious, gasping for air. Despite the administration of 100% oxygen by mask, the patient continues to have labored breathing, accessory muscle use, and a SpO2 of 83%. The patient remains hemodynamically stable. Which of the following is the MOST appropriate next step?
Explanation
The two primary anesthetic considerations with mediastinal masses include the possibility of airway collapse and the potential for vascular compression. Preoperative signs and symptoms of bronchiolar or tracheal collapse may include cough, dyspnea, orthopnea, or stridor. Preoperative symptoms of vascular compression include lightheadedness, visual disturbances, or syncope. Asymptomatic compression may be recognized as tracheal deviation on a chest radiograph or bronchial, tracheal, or vascular compression on computed tomography. Evidence of superior vena cava syndrome on physical exam may be associated with severe airway obstruction and cardiovascular collapse on induction of general anesthesia. Premedication should be avoided, adequate intravenous access should be obtained, and standard monitors including an arterial line should be placed. The anesthetic plan should take into consideration the possibility of difficulties with ventilation and intubation. After preoxygenation, a smooth induction maintaining spontaneous ventilation and hemodynamic stability should be performed. Awake intubation may be optimal in a cooperative patient, but straining or coughing may lead to increased positive pleural pressure and worsen tracheal compression, as it did in this question. Thus, adequate local anesthesia is paramount. In uncooperative patients, a slow inhalation induction or intravenous ketamine should be considered. If contraindications exist, incremental doses of propofol or etomidate may need to be used. Regardless, paralysis should be avoided during induction. Loss of spontaneous ventilation can precipitate complete airway obstruction.
References:
Mediastinal Masses: Adults, MediastinoscopyMcGoldrick KE. Anesthesia for Thoracic Surgery. Chapter 24. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M, Stock MC, Ortega R, eds., Clinical Anesthesia. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013
OA Series: April 2025
14:58
PAINTS
Feedback in the Clinical SettingJamie Rubin, MD, Oregon Health & Science University, Portland, OR
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42:37
OA-SPA Pediatric Anesthesia Virtual Grand Rounds
Obesity & AnesthesiaJamey E. Eklund, MD, DABOM, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
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