Letters to Editor
the attending surgeons and the anesthesiologists of the issues related to the airway. In a similar scenario (airway compression by a cyst), Tempe et al. recommended to relieve the compression of the airway before definitive surgery.[2] The clinical and imaging information indicate a single stage debulking of the tumor like that for cervical/ thoracic dumbbell tumors with airway compromise.[3] The anesthesia approach would have been on the lines of managing a patient with difficult airway including short acting anesthetic agents, avoidance of muscle relaxants and maintenance of spontaneous respiration. In the present patient, while the patient underwent spinal decompression in prone position, the authors chose to manage anesthesia in a routine manner like any other case and at the end of surgery, turned the patient supine, reversed the neuromuscular block and after ensuring return of adequate spontaneous breathing and upper airway reflexes extubated the trachea. The upper airway is known to become edematous after a prone position surgery. It should also be appreciated that following a long duration propofol infusion delayed recovery of the patient due to delayed elimination of the drug from the third space is expected, the recovery can be further delayed if the patient is obese and large. It is now difficult to assess the cause of post-operative airway crisis with no mention of patient weight, duration of surgery and the responses to train of four that would have shed some light on the cause of immediate respiratory distress. Erdös et al.[4] have assigned “severity grade” for difficult airway using a three-grade clinical classification scale: “safe,” “uncertain,” and “unsafe”, whereby each stage triggers appropriate action in terms of staffing and apparatus, such as the provision of alternatives for airway management, cardiopulmonary bypass and additional specialists. In the case of patients classified as “safe” or “uncertain,” a pre-operative consensus with the surgeons should be reached as to the anesthetic approach and the management of possible complications.[4] In this patient, the presence of adequate luminogram on radiograph and contrastenhanced computed tomography might have led to misinterpretation of the underlying airway pathology. However, from the radiology point of view airway displacement and loss of contour and compression was evident. The plan of surgery and anesthesia should have taken these findings in consideration and modified the management suitable for that of an airway compression.
Subrata Kumar Singha, Narendra Kuber Bodhey1 1
Departments of Anesthesiology, and Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
Address for correspondence: Dr. Narendra Kuber Bodhey, Additional Prof. & Head, Department of Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India. E-mail: [email protected]
REFERENCES 1.
Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much? Ann Card Anaesth 2013;16:289-92. 2. Tempe DK, Datt V, Virmani S, Tomar AS, Banarjee A, Goel S, et al. Aspiration of a cystic mediastinal mass as a method of relieving airway compression before definitive surgery. J Cardiothorac Vasc Anesth 2005;19:781-3. 3. Ando K, Imagama S, Wakao N, Hirano K, Tauchi R, Muramoto A, et al. Single-stage removal of thoracic dumbbell tumors from a posterior approach only with costotransversectomy. Yonsei Med J 2012;53:611-7. 4. Erdös G, Tzanova I. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol 2009;26:627-32. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.124158
Authors’ reply The Editor, We thank Singha et al.[1] for their interest in our article, “Posterior mediastinal mass: Do we need to worry much”[2] and making constructive comments. It is agreed that, cervicothoracic sign, a variant of silhouette sign, which can be seen in lesions of apical segments of upper lobes, pleura, or posterior mediastinum,[3] was indeed positive, as can be seen in the chest X-ray shown in the referred article. The compression on the vertebral body and intraspinal extension of the mass was seen in the computed tomography scans and was further confirmed by magnetic resonance imaging. These images were not shown in the referred article but these findings were confirmed by a senior radiologist of our institute. Decision for two-stage surgery was taken after multidisciplinary team discussion, which included the operating neuro-surgeon and the cardiothoracic surgeon. The team opined that spinal cord compression in the context of deteriorating neurological function represents a neurosurgical emergency. 73
Letters to Editor
The mass was abutting the trachea and the right main bronchus causing their displacement and some degree of compression but as evident in coronal view of contrast enhanced computed tomography chest shown in the article, air luminogram was maintained. Considering insignificant external compression and absence of any airway compressive symptoms in both supine position and during sleep, normal routine anesthesia management including induction was carried out in this patient. It is agreed that in the present case with a history of mass for more than 1 year, anesthesia induction, propofol infusion, long duration of surgery (5 hours) in prone position may all have contributed to the airway compromise that followed the tracheal extubation after the surgery. In retrospect, it is clear that presence of airway compression/displacement on imaging and/or the symptoms of airway compromise in presence of posterior mediastinal mass should not be taken lightly. In such cases interdisciplinary team discussion (anesthesiology, surgery, radiology, pathology and otolaryngology), clinical assessment, careful planning and vigilance is required. A lack of symptoms in the pre-operative evaluation in such patients, does not guarantee an uneventful anesthetic course and all the necessary arrangements including rigid bronchoscope and cardiopulmonary bypass should be made depending upon the severity and involvement to prevent airway catastrophe.
Parin Lalwani, Rajiv Chawla, Mritunjay Kumar, Akhilesh S. Tomar, Padmalatha Raman Departments of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi, India Address for correspondence: Dr. Rajiv Chawla, Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi - 110 002, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
Singha S, Bodhey N. In response to “Posterior mediastinal mass: Do we need to worry much ?” Ann Card Anaesth 2014;17:72-3. Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much? Ann Card Anaesth 2013;16:289-92. Kazerooni EA, Gross BH. Cardiopulmonary Imaging. Philadelphia, PA. Lippincott Williams & Wilkins; 2004. p. 206. Access this article online Quick Response Code:
Website: www.annals.in
74
Unexplained desaturation following a Glenn shunt The Editor, A 2‑year‑old child weighing 9 kg presented with cyanosis since birth. The peripheral saturation on room air was 45%. Echocardiogram revealed situs solitus, levocardia, unbalanced atrio‑ventricular septal defect, malposed great arteries and severe pulmonary stenosis with a peak gradient of 70 mmHg. The pulmonary veins were draining normally. Angiography showed borderline right pulmonary artery, good size left pulmonary artery, right superior vena cava (RSVC) and innominate vein. There was no left superior vena cava (LSVC). Patient was scheduled for bi‑directional Glenn (BDG) shunt. After median sternotomy, right lobe of thymus was excised and pericardiotomy done. Intraoperatively, pulmonary arteries were about 6 mm each, but with uniform caliber throughout, with good sized innominate vein and RSVC. Mean pulmonary artery pressure was 15 mmHg. A BDG (cavopulmonary anastomosis) was performed on cardiopulmonary bypass. Following surgery, the Glenn pressure was 19 mmHg with antegrade flow preserved and 17 mmHg with main pulmonary artery (MPA) ligated. However, unexpectedly, patient’s saturation was only 50%. In view of low saturation, MPA was not ligated and patient was shifted to intensive care unit. Post‑operatively, over few hours, saturation dipped to 25%. However, clinically the patient improved with good urine output and decrease in facial puffiness. Chest X‑ray showed non‑oligemic lung fields. Echocardiogram showed good Glenn flow and contrast echocardiogram performed by injecting agitated saline through the left brachial vein showed no LSVC. The options considered were to perform a cardiac catheterization with oximetry studies, Glenn takedown with Blalock‑Taussig shunt or re‑exploration with oximetry performed on the operating table by the surgeon to locate the possible site of a right to left shunt. It was decided to take up the patient for re‑exploration. On re‑exploration, the left lobe of thymus was removed and to our surprise, a big LSVC was noted [Figure 1]. This was ligated following which systemic saturation immediately Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
the attending surgeons and the anesthesiologists of the issues related to the airway. In a similar scenario (airway compression by a cyst), Tempe et al. recommended to relieve the compression of the airway before definitive surgery.[2] The clinical and imaging information indicate a single stage debulking of the tumor like that for cervical/ thoracic dumbbell tumors with airway compromise.[3] The anesthesia approach would have been on the lines of managing a patient with difficult airway including short acting anesthetic agents, avoidance of muscle relaxants and maintenance of spontaneous respiration. In the present patient, while the patient underwent spinal decompression in prone position, the authors chose to manage anesthesia in a routine manner like any other case and at the end of surgery, turned the patient supine, reversed the neuromuscular block and after ensuring return of adequate spontaneous breathing and upper airway reflexes extubated the trachea. The upper airway is known to become edematous after a prone position surgery. It should also be appreciated that following a long duration propofol infusion delayed recovery of the patient due to delayed elimination of the drug from the third space is expected, the recovery can be further delayed if the patient is obese and large. It is now difficult to assess the cause of post-operative airway crisis with no mention of patient weight, duration of surgery and the responses to train of four that would have shed some light on the cause of immediate respiratory distress. Erdös et al.[4] have assigned “severity grade” for difficult airway using a three-grade clinical classification scale: “safe,” “uncertain,” and “unsafe”, whereby each stage triggers appropriate action in terms of staffing and apparatus, such as the provision of alternatives for airway management, cardiopulmonary bypass and additional specialists. In the case of patients classified as “safe” or “uncertain,” a pre-operative consensus with the surgeons should be reached as to the anesthetic approach and the management of possible complications.[4] In this patient, the presence of adequate luminogram on radiograph and contrastenhanced computed tomography might have led to misinterpretation of the underlying airway pathology. However, from the radiology point of view airway displacement and loss of contour and compression was evident. The plan of surgery and anesthesia should have taken these findings in consideration and modified the management suitable for that of an airway compression.
Subrata Kumar Singha, Narendra Kuber Bodhey1 1
Departments of Anesthesiology, and Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
Address for correspondence: Dr. Narendra Kuber Bodhey, Additional Prof. & Head, Department of Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India. E-mail: [email protected]
REFERENCES 1.
Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much? Ann Card Anaesth 2013;16:289-92. 2. Tempe DK, Datt V, Virmani S, Tomar AS, Banarjee A, Goel S, et al. Aspiration of a cystic mediastinal mass as a method of relieving airway compression before definitive surgery. J Cardiothorac Vasc Anesth 2005;19:781-3. 3. Ando K, Imagama S, Wakao N, Hirano K, Tauchi R, Muramoto A, et al. Single-stage removal of thoracic dumbbell tumors from a posterior approach only with costotransversectomy. Yonsei Med J 2012;53:611-7. 4. Erdös G, Tzanova I. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol 2009;26:627-32. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.124158
Authors’ reply The Editor, We thank Singha et al.[1] for their interest in our article, “Posterior mediastinal mass: Do we need to worry much”[2] and making constructive comments. It is agreed that, cervicothoracic sign, a variant of silhouette sign, which can be seen in lesions of apical segments of upper lobes, pleura, or posterior mediastinum,[3] was indeed positive, as can be seen in the chest X-ray shown in the referred article. The compression on the vertebral body and intraspinal extension of the mass was seen in the computed tomography scans and was further confirmed by magnetic resonance imaging. These images were not shown in the referred article but these findings were confirmed by a senior radiologist of our institute. Decision for two-stage surgery was taken after multidisciplinary team discussion, which included the operating neuro-surgeon and the cardiothoracic surgeon. The team opined that spinal cord compression in the context of deteriorating neurological function represents a neurosurgical emergency. 73
Letters to Editor
The mass was abutting the trachea and the right main bronchus causing their displacement and some degree of compression but as evident in coronal view of contrast enhanced computed tomography chest shown in the article, air luminogram was maintained. Considering insignificant external compression and absence of any airway compressive symptoms in both supine position and during sleep, normal routine anesthesia management including induction was carried out in this patient. It is agreed that in the present case with a history of mass for more than 1 year, anesthesia induction, propofol infusion, long duration of surgery (5 hours) in prone position may all have contributed to the airway compromise that followed the tracheal extubation after the surgery. In retrospect, it is clear that presence of airway compression/displacement on imaging and/or the symptoms of airway compromise in presence of posterior mediastinal mass should not be taken lightly. In such cases interdisciplinary team discussion (anesthesiology, surgery, radiology, pathology and otolaryngology), clinical assessment, careful planning and vigilance is required. A lack of symptoms in the pre-operative evaluation in such patients, does not guarantee an uneventful anesthetic course and all the necessary arrangements including rigid bronchoscope and cardiopulmonary bypass should be made depending upon the severity and involvement to prevent airway catastrophe.
Parin Lalwani, Rajiv Chawla, Mritunjay Kumar, Akhilesh S. Tomar, Padmalatha Raman Departments of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi, India Address for correspondence: Dr. Rajiv Chawla, Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi - 110 002, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
Singha S, Bodhey N. In response to “Posterior mediastinal mass: Do we need to worry much ?” Ann Card Anaesth 2014;17:72-3. Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much? Ann Card Anaesth 2013;16:289-92. Kazerooni EA, Gross BH. Cardiopulmonary Imaging. Philadelphia, PA. Lippincott Williams & Wilkins; 2004. p. 206. Access this article online Quick Response Code:
Website: www.annals.in
74
Unexplained desaturation following a Glenn shunt The Editor, A 2‑year‑old child weighing 9 kg presented with cyanosis since birth. The peripheral saturation on room air was 45%. Echocardiogram revealed situs solitus, levocardia, unbalanced atrio‑ventricular septal defect, malposed great arteries and severe pulmonary stenosis with a peak gradient of 70 mmHg. The pulmonary veins were draining normally. Angiography showed borderline right pulmonary artery, good size left pulmonary artery, right superior vena cava (RSVC) and innominate vein. There was no left superior vena cava (LSVC). Patient was scheduled for bi‑directional Glenn (BDG) shunt. After median sternotomy, right lobe of thymus was excised and pericardiotomy done. Intraoperatively, pulmonary arteries were about 6 mm each, but with uniform caliber throughout, with good sized innominate vein and RSVC. Mean pulmonary artery pressure was 15 mmHg. A BDG (cavopulmonary anastomosis) was performed on cardiopulmonary bypass. Following surgery, the Glenn pressure was 19 mmHg with antegrade flow preserved and 17 mmHg with main pulmonary artery (MPA) ligated. However, unexpectedly, patient’s saturation was only 50%. In view of low saturation, MPA was not ligated and patient was shifted to intensive care unit. Post‑operatively, over few hours, saturation dipped to 25%. However, clinically the patient improved with good urine output and decrease in facial puffiness. Chest X‑ray showed non‑oligemic lung fields. Echocardiogram showed good Glenn flow and contrast echocardiogram performed by injecting agitated saline through the left brachial vein showed no LSVC. The options considered were to perform a cardiac catheterization with oximetry studies, Glenn takedown with Blalock‑Taussig shunt or re‑exploration with oximetry performed on the operating table by the surgeon to locate the possible site of a right to left shunt. It was decided to take up the patient for re‑exploration. On re‑exploration, the left lobe of thymus was removed and to our surprise, a big LSVC was noted [Figure 1]. This was ligated following which systemic saturation immediately Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
