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Achondroplasia: Considerations

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1. Most common form of dwarfism (more than 100 other types). Autosomal dominant inheritance Appearance: large head-to-body size difference, prominent forehead, shortened arms and legs, decreased muscle tone 2. Airway management difficulties Craniofacial and spinal abnormalities: • limited neck extension • foramen magnum stenosis • large tongue • large mandible • atlanto-axial instability 3. Kyphosis, scoliosis, and spinal stenosis: difficult and unpredictable spread of local anesthetics in epidural and subarachnoid spaces 4. Comorbidities: central and obstructive sleep apnea, otitis media (childhood), obesity

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Achondroplasia: History

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• Pain/ataxia/incontinence/apnea—due to cervicomedullary/spinal cord compression

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Achondroplasia: Physical Exam

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• Neurologic—hypotonia in infancy • Craniofacial features—large head, midface hypoplasia, dental crowding • Short stature (normal trunk length) • Bow legs (genuvarum)

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Achondroplasia: Lab Tests/Imaging

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*Polysomnography (assess CSA/OSA) *Head/neck CT/MRI (assess craniocervical junction)

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Achondroplasia: Consults

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• Neurology as indicated from history and exam

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Achondroplasia: Conflicts

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• Endotracheal intubation and cervical instability • CSA/OSA and use of sedatives/analgesics • Regional anesthesia and spinal/neurologic abnormalities

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Achondroplasia: Optimize/Goals

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• Minimize movement of cervical spine during ETT placement (consider referral to neurology if new onset/worsening symptoms) • Consider adjuvants to opioids for pain management regarding OSA • Consider imaging techniques before regional anesthesia to assess anatomy of vertebrae and spinal cord; also consider epidural versus spinal (titratable)

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Achondroplasia: Options

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• General anesthesia, regional anesthesia, or sedation

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Achondroplasia: Preop

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*Premed *Blood: as indicated by surgical procedure *ICU/stepdown bed: consider severity of OSA

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Achondroplasia: Room Setup (Special drugs/Monitors)

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• Difficult airway cart available • Body size appropriate airways/laryngoscopes • Consider use of alternative analgesics than opioids (dexmedetomidine, low-dose ketamine, regional)

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Achondroplasia: Induction

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•If GETA—consider AFOI as determined from airway/C-spine assessment •If regional—use smaller doses of LA; beware high block

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Achondroplasia: Maintenance

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•Maintain neck in neutral position •Positioning—consider patient's body habitus

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Achondroplasia: Emergence

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•If difficult intubation—consider leaving ETT in place or extubating fully awake, use of tube exchanger

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Achondroplasia: Recovery

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•Recovery/Stepdown/ICU as required

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Achondroplasia: Clinical Pearls

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*For the achondroplastic obstetric patient—consider imaging early in pregnancy to assess lumbar anatomy during labor—early placement of epidural catheter to allow for slow titration.

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Acromegaly: Considerations

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1. GH hypersecretion. Usually from GH secreting pituitary adenoma—may be complicated by headaches, visual field defects, elevated ICP, hypopituitarism (requires replacement with hydrocortisone/thyroxine) 2. Potentially difficult airway/difficult ventilation: gigantism, facial changes, large tongue, hypertrophy of pharyngeal mucosa, small glottic opening, prominent jaw (prognathism), obstructive sleep apnea (OSA) 3. Comorbidities: OSA, hypertension, cardiac arrhythmias, diastolic dysfunction (heart failure), coronary artery disease, glucose intolerance, renal failure, arthritis, kyphoscoliosis 4. Treatments: pituitary surgery (transsphenoidal), radiotherapy, medical (octreotide—suppresses GH secretion)

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Acromegaly: History

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• Comorbidities: duration, severity, and functional capacity/limitations • Respiratory—apnea, snoring, somnolence, PH OSA, use of CPAP, PH of difficult intubation? • Cardiac disease—HTN? Angina? Exercise capacity? • Therapies: medical, radiotherapy, surgical?

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Acromegaly: Physical Exam

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• Body habitus/BMI • Airway—hypertrophy of facial bones, mandible, tongue • Vital signs—hypertension? • Heart failure—tachycardia, elevated JVP, S3/S4, hepatomegaly, peripheral/pulmonary edema

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Acromegaly: Lab Tests/Imaging

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• CBC—anemia? Electrolytes—hyponatremia, ↓K, hyperglycemia? • TSH—thyroid function? • EKG/echocardiography—LV hypertrophy? Systolic/diastolic dysfunction?

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Acromegaly: Conflict(s)

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• Potential difficult airway/difficult mask ventilation (requiring AFOI) and potential cardiac disease (avoid further "stress"—hypertension, tachycardia) • OSA and use of opioids for analgesia

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Acromegaly: Optimize/Goals

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• Hypopituitarism—ensure hydrocortisone/thyroxine therapy as required (consider preop. endocrine consult) • If difficult airway—prepare for AFOI • If OSA—minimize use of opioids, constant positive airway pressure (CPAP) postoperative • If heart failure—minimize further depression of cardiac function, optimize fluid therapy

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Acromegaly: Options

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• General anesthesia, regional anesthesia, peripheral nerve blocks, or sedation

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Acromegaly: Preop

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*Premed: ±steroids *Blood: surgery dependent *ICU/stepdown bed: possibly given comorbidities

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Acromegaly: Room Setup (Special Drugs/Monitors)

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• Depending on patient size—may require larger-sized equipment (OR table, NIBP cuff) • Consider invasive BP monitor • Difficult airway cart—fiberoptic video laryngoscope

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Acromegaly: Induction

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• Consider AFOI

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Acromegaly: Maintenance

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• Optimize based on comorbidities

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Acromegaly: Emergence

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• Fully awake for extubation; if OSA, consider early use of CPAP

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Acromegaly: Disposition/Pain

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• PACU/ICU/stepdown as required • Minimize opioids, consider adjuvants/nerve blocks

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Acromegaly: Clinical Pearls

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For transsphenoidal pituitary surgery: the acromegalic patient will require oral intubation (regular or RAE tube) and the procedure is generally done in the sitting position. Complications include cranial nerve injury (II-VI), bleeding, CSF leak, DI (treat with DDAVP), or SIADH (fluid restrict).

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Acute Porphyrias: Considerations

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1. Group of inherited enzymatic defects of heme synthesis, characterized by overproduction of heme precursors and intermittent symptomatic attacks 2. Multisystem manifestations including neurological, renal, cardiovascular 3. Drugs triggering attacks (wide range, but including): • barbiturates • ergots • metoclopramide • steroids 4. Nondrug triggers: dehydration, fasting, stress, infection

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Acute Porphyrias: History

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• History of attacks: abdominal pain, vomiting, fever, hallucinations, mental status changes, seizures (acute intermittent porphyria), blistering skin lesions (variegate porphyria) • Prior anesthetic and specific drugs used

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Acute Porphyrias: Physical Exam

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• Signs of autonomic dysfunction (HTN, ↑HR) • Assess intravascular volume status • Neuro exam (weakness, bulbar involvement, respiratory failure) • Abdominal exam often normal

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Acute Porphyrias: Lab Tests/Imaging

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• Electrolytes (↓Na, ↓K, ↓Ca) • Urine porphyrin & porphyrinogen precursors • Red/purple urine

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Acute Porphyrias: Optimize

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• Carbohydrate loading suppresses the synthesis of porphyrins. Start IV with D10W (or D5LR if hyponatremic)

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Acute Porphyrias: Options

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• Regional anesthesia probably safe but take care with preexisting neurologic deficits

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Acute Porphyrias: Preop

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*Premed *Blood *ICU/stepdown bed

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Acute Porphyrias: Maintenance

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• Expect labile BP; volatiles safe

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Acute Porphyrias: Disposition/Pain

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• Observe 24 hours for attack

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Acute Porphyrias: Clinical Pearls

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• The enzyme ALA synthetase is inducible by a wide variety of drugs, or by events that lead to an increased requirement for heme. The deficiency of various enzymes (depending on the type of porphyria) further along the biochemical pathway causes accumulation of precursors. • The acute porphyrias are: • acute intermittent porphyria (most severe, mortality up to 10% with attacks) • variegate porphyria • hereditary coproporphyria • All acute porphyrias share neurologic symptoms as a common feature. These are numerous and include autonomic and peripheral neuropathy, bulbar involvement, hypothalamic dysfunction, mental status changes, seizures, and coma. Many of the neurologic deficits can be permanent. • If crisis: • remove trigger/end surgery • IV hydration with dextrose • hematin 3 to 4 mg/kg IV (inhibits ALA synthetase) • treat nausea and vomiting with antiemetics • treat pain with opioids • beta blockers for hypertension/tachycardia • if seizures, midazolam, NOT phenytoin • monitor electrolytes and treat accordingly • "Unsafe drugs" for anesthesia or drugs with unproven safety: • barbituates, etomidate, ropivacaine, hydralazine, nifedipine, phenyoxybenzamine, pentazocine

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Adrenal Insufficiency: Considerations

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1. Establish cause: primary (failure to produce cortisol/aldosterone) versus secondary (failure to produce adrenocorticotropic hormone [ACTH]) 2. DDx: primary—autoimmune destruction of adrenal glands, autoimmune polyendocrine deficiency syndromes, other infections (TB, AIDS), surgical removal; secondary causes—lack of ACTH from abrupt discontinuation of chronic steroids, hypopituitarism (tumors, radiation, surgery, drugs—etomidate, ketoconazole) 3. Addisonian crisis: back/leg/abdominal pain, vomiting, diarrhea, dehydration, hypotension, and loss of consciousness 4. Surgery—may require "stress" dose glucocorticoids

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Adrenal Insufficiency: History

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• Fatigue/headache • Muscle weakness • Loss of appetite/weight loss/nausea/vomiting

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Adrenal Insufficiency: Physical Exam

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• Altered mental status • Orthostatic hypotension • Hyperpigmentation (Addison's Disease)

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Adrenal Insufficiency: Lab Tests/Imaging

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• Electrolytes (hyponatremia, ↓K, hypoglycemia) • Serum cortisol (low), ACTH (high) • BUN/Creatinine—prerenal failure

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Adrenal Insufficiency: Consults

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*Endocrine

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Adrenal Insufficiency: Conflict(s)

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• Avoid elective/urgent procedures if Addisonian crisis

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Adrenal Insufficiency: Optimize/Goals

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• Addisonian crisis—treat with hydrocortisone 100 mg IV q6h, fludrocortisone, fluid resuscitation (NS), dextrose, and vasopressors as required • May require supplemental "stress" dose hydrocortisone in perioperative period • Adequate fluid resuscitation, supplement, and/or maintenance of electrolytes

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Adrenal Insufficiency: Options

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• General, regional, local, peripheral nerve block, or sedation • Altered mental status, vomiting—will require GETA/RSI

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Adrenal Insufficiency: Preop

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*Premed: steroids *Blood: surgery dependent *ICU/stepdown bed: possibly

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Adrenal Insufficiency: Room Setup (Special Drugs/Monitors)

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• Standard monitors ± Foley catheter • Consider A-line (BP, electrolyte monitoring) or central line, if requires large volume fluid resuscitation and/or vasopressors • Treatments for hyperkalemia (insulin, dextrose, sodium bicarbonate)

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Adrenal Insufficiency: Induction

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• Often requires GETA/RSI (avoid etomidate)

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Adrenal Insufficiency: Maintenance

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*Balance technique

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Adrenal Insufficiency: Emergence

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*Routine

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Adrenal Insufficiency: Disposition/Pain

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• PACU, stepdown, ICU as required

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Adrenal Insufficiency: Clinical Pearls

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"Stress dose" steroids are given to prevent adrenal crises in the perioperative period for patients with adrenal insufficiency. Keep in the mind the concept of "stress dose" steroids for the perioperative period is controversial. The correct dose and frequency of corticosteroid administration are not standardized. Some believe that it is sufficient to simply continue the patient's current dose of corticosteroid throughout the perioperative period without an additional "stress" dose.

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Adrenocortical Excess (Cushing Syndrome): Considerations

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1. Differentiation of source of corticosteroid excess: pituitary (Cushing disease), adrenal, paraneoplastic, or exogenous (oral steroids) 2. Potential for ↑ICP 3. Left ventricular hypertrophy (esp. asymmetric septal hypertrophy) with systolic and diastolic dysfunction 4. ↑Incidence of OSA 5. ↑Sensitivity to catecholamines 6. Increased infection and poor wound healing

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Adrenocortical Excess (Cushing Syndrome): History

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• Symptoms of pituitary tumor: headache, bitemporal hemianopsia, ↓libido (hyperprolactinemia), thirst (DI) • Weight gain, weakness, lethargy, easy bruising, baldness, hirsutism, acne, hyperhidrosis • Psychosis, depression • Snoring, somnolence

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Adrenocortical Excess (Cushing Syndrome): Physical Exam

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• "Moon" facies, striae, supraclavicular and cervical fat pads • Careful volume assessment. HTN? • Papilledema if ↑ICP • Signs of pulmonary HTN, cor pulmonale if OSA

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Adrenocortical Excess (Cushing Syndrome): Lab Tests/Imaging

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• CBC (↑Hb), electrolytes (↑K, ↓ Ca++), glucose • EKG (LVH, strain), ± echo if indicated

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Adrenocortical Excess (Cushing Syndrome): Consults

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• Endocrinology

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Adrenocortical Excess (Cushing Syndrome): Optimize

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• Treat hypertension if severe • Treat OSA preoperatively for 6 to 8 weeks if signs of pulmonary HTN/cor pulmonale/erythrocytosis

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Adrenocortical Excess (Cushing Syndrome): Goals

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• Careful management of perioperative glucose → stress response of surgery/trauma leads to ↑cortisol

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Adrenocortical Excess (Cushing Syndrome): Options

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• May be difficult brachial plexus block → obesity/supraclavicular fat pad

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Adrenocortical Excess (Cushing Syndrome): Preop

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*Premed *Blood *ICU/stepdown bed

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Adrenocortical Excess (Cushing Syndrome): Room Setup (Special drugs/Monitors)

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• Mannitol if↑ICP • ± Difficult airway cart if predicted

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Adrenocortical Excess (Cushing Syndrome): Disposition/Pain

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• If resection of ACTH/cortisol secreting tumor, follow serum cortisol levels q6h and treat if laboratory evidence of adrenal insufficiency (ie, no empiric corticosteroid Rx)

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Alcoholism: Considerations

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1. Multisystem disease: Neuro—peripheral neuropathy, Wernicke-Korsakoff syndrome (ocular signs, ataxia, confusion) CVS—acute: tachycardia, hypertension; cardiomyopathy, palpitations, arrhythmias. Respiratory—comorbid: smoking, pneumonia, abscesses GI—reflux, gastritis, pepticulcers Liver—fatty liver, hepatitis, cirrhosis Pancreas—pancreatitis Heme—pancytopenia 2. Chronic consumption: induction of liver enzymes and increased metabolism of other drugs (cross-tolerance) 3. Risk of alcohol withdrawal syndrome: tremors, sweating, nausea, vomiting, seizures (DTs within 48-72 hours post-alcohol cessation) 4. Avoid acetaminophen: higher risk of liver damage

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Alcoholism: History

answer

• Screen for alcohol consumption/withdrawal symptoms • Screen for polysubstance abuse, smoking • Capacity for consent? Alternate decision maker?

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Alcoholism: Physical Exam

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• Neuro—mental status, encephalopathy, tremors • Stigmata of cirrhosis—jaundice, scleral icterus, ascites, spider angioma

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Alcoholism: Lab Tests/Imaging

answer

• CBC, electrolytes, BUN/Cr, coags, LFTs • Electrocardiography (EKG)

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Alcoholism: Consults

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• Addiction/psychiatry

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Alcoholism: Conflict

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• Poorly optimized (inadequate preoperative care, noncompliant) but often present for emergency surgery

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Alcoholism: Optimize/Goals

answer

• Prevent withdrawal, supplement nutrition—long-lasting benzodiazepines (diazepam, chlordiazepoxide) and thiamine supplementation (po/IV) • General anesthesia—acute intoxication—more sensitive to anesthetics; chronic intake—tolerant to anesthetics • May require FFP/platelet transfusion if coagulopathy

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Alcoholism: Options

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• General, regional, local, peripheral nerve block, or sedation • Often full stomach requiring GETA • Cooperation may preclude regional/PNB techniques

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Alcoholism: Preop

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*Premed: benzodiazepine, GI prophylaxis *Blood: surgery dependent *ICU/stepdown bed: possibly

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Alcoholism: Room Setup (Special Medications/Monitors)

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• Std monitors ± Foley catheter

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Alcoholism: Induction

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• RSI for intoxicated patients, cirrhosis/ascites • Chronic—require larger doses of induction agents (mindful of cardiomyopathy)

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Alcoholism: Maintenance

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• Balanced technique

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Alcoholism: Emergence

answer

• Beware of postoperative agitation/confusion

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Alcoholism: Disposition/Pain

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• PACU, stepdown, ICU as required

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Amyotrophic Lateral Sclerosis (ALS): Considerations

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1. Aspiration risk due to bulbar palsy 2. Altered responses to neuromuscular blockers Succinylcholine—hyperkalemia NDMR—prolonged response 3. ↑Risk for requiring postoperative PPV 4. Potential autonomic dysfunction 5. Ethical issues surrounding preservation of life versus minimizing suffering

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Amyotrophic Lateral Sclerosis (ALS): History

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• H/o dysarthria, dysphagia • H/o ventilatory support (eg, BiPAP)

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Amyotrophic Lateral Sclerosis (ALS): Physical Exam

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• Skeletal muscle atrophy, weakness, fasciculations • Hyperreflexia • Orthostatic hypotension • Resting tachycardia

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Amyotrophic Lateral Sclerosis (ALS): Lab Tests/Imaging

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• CXR—pneumonia; association with lung ca • Electrolytes, glucose (↓ K, hyperglycemia) • PFTs: ↓ VC, PFR • ABG

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Amyotrophic Lateral Sclerosis (ALS): Conflict(s)

answer

• Full stomach versus hyperkalemia with succinylcholine

question

Amyotrophic Lateral Sclerosis (ALS): Optimize

answer

• Treat pneumonia if present

question

Amyotrophic Lateral Sclerosis (ALS): Goals

answer

• Avoid worsening respiratory depression

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Amyotrophic Lateral Sclerosis (ALS): Options

answer

• GA but care with respiratory depressants • Epidural, spinal, and CSE have all been used without neurologic exacerbation, and may be excellent choice for avoiding GA

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Amyotrophic Lateral Sclerosis (ALS): Preop

answer

*Premed: care with respiratory depressants *Blood *ICU/stepdown bed: as needed

question

Amyotrophic Lateral Sclerosis (ALS): Induction

answer

• Modified RSI with rocuronium

question

Amyotrophic Lateral Sclerosis (ALS): Maintenance

answer

• ↓Doses of NDMRs • Careful neuromuscular monitoring

question

Amyotrophic Lateral Sclerosis (ALS): Emergence

answer

• Fully awake

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Amyotrophic Lateral Sclerosis (ALS): Disposition/Pain

answer

• Avoid opioids if possible—multimodal analgesia/RA • Postoperative chest physio, incentive spirometry

question

Ankylosing Spondylitis: Considerations

answer

1. AS—chronic inflammatory arthritis (HLA B-27 association) Affects mainly spine and sacroiliac joints ("bamboo spine") and insertion sites of ligaments/tendons Spine—fractures/collapse and nerve root/cord compression, cauda equina syndrome Comorbidity—ulcerative colitis/Crohn, psoriasis, uveitis Airway—potentially difficult (C-spine, TMJ involvement) Often present for hip/shoulder/spine surgery Extra-articular—CV (aortic insufficiency, conduction defects, MI) resp (restrictive defect), eye (uveitis) 2. Therapy—physiotherapy, NSAIDs, methotrexate, bisphosphonates, anti-TNF-alpha, intra-articular steroids, joint replacements/spinal surgery 3. Anti-TNF-alpha agents—increased risk of infection (TB), may worsen CHF—consider holding perioperative

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Ankylosing Spondylitis: History

answer

• Pain assessment; morning stiffness (improves with exercise) • Evaluate articular and extra-articular symptoms • General—weight loss, fatigue

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Ankylosing Spondylitis: Physical Exam

answer

• Neuro—ROM of joints, muscle strength, sensation (paresthesias) • Rigid hyperkyphotic deformity of spine "hump," limited ROM in lumbar spine, limited chest expansion • Unsteady gait • CV—large volume pulse (water-hammer), diastolic murmur (AI)

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Ankylosing Spondylitis: Lab Tests/Imaging

answer

• Pending severity: ECG, echocardiography, PFTs, C-spine imaging, ABG

question

Ankylosing Spondylitis: Consults

answer

• Rheumatology

question

Ankylosing Spondylitis: Conflict(s)

answer

• GETA and involvement of cervical spine/TMJ—difficult intubation and potentially impossible tracheostomy (if fixed flexion defect)

question

Ankylosing Spondylitis: Optimize/Goals

answer

• Consider preoperative imaging or indirect laryngoscopy to assess airway • AFOI is primary option; alternatives include ILMA, video laryngoscope • Spinal/epidural anesthesia—technically difficult; consider use of ultrasound to assess feasibility • Beware high block (smaller epidural space)

question

Ankylosing Spondylitis: Options

answer

• General, regional, local, peripheral nerve block, or sedation often require AFOI

question

Ankylosing Spondylitis: Preop

answer

*Premed: ±steroids *Blood: surgery dependent * ICU/stepdown bed: possibly

question

Ankylosing Spondylitis: Room Setup (Special Drugs/Monitors)

answer

• Std monitors ± Foley catheter • Difficult airway cart/video laryngoscope • Procedures requiring neuro monitoring (MEPs)—avoid muscle relaxants

question

Ankylosing Spondylitis: Induction

answer

• Optimize positioning • AFOI; backup equipment available

question

Ankylosing Spondylitis: Maintenance

answer

• Balanced technique (mindful of SSEP/MEPs)

question

Ankylosing Spondylitis: Emergence

answer

• Minimize neck movement, care when transferring patient, early institution of chest physiotherapy

question

Ankylosing Spondylitis: Disposition

answer

• PACU, stepdown, ICU as required

question

Anterior Mediastinal Mass: Considerations

answer

1. Risk of death from airway obstruction and/or cardiovascular collapse 2. Anatomy—location, size, degree of airway/CV compromise? (Children: tracheobronchial compression >50% precludes safe GETA) 3. Pathology—benign or malignant tumors, cysts, or aneurysms. Most common—Hodgkin's lymphoma or NHL 4. Proposed surgical procedure—usually for diagnosis: sternotomy, thoracotomy, mediastinoscopy (cervical or anterior parasternal), VATS, or extrathoracic mass biopsy. May also present for emergency surgery of other nature 5. If unsafe for GA— 1) other options to get tissue for diagnosis: extrathoracic mass/lymph node for biopsy or CT-guided needle biopsy or awake anterior mediastinoscopy with LA, or... 2) consider empiric chemo/radiotherapy to decrease size of mass 6. May require ECMO or cardiopulmonary bypass

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Anterior Mediastinal Mass: History

answer

• Chest pain/fullness • Dyspnea/cough/orthopnea • Night sweats/fever/fatigue • Hoarseness/dysphagia • Syncope • Asymptomatic (noted on imaging study)

question

Anterior Mediastinal Mass: Physical Exam

answer

• Acute distress? • Lymphadenopathy, fever • Pericardial rub • Stridor, cyanosis, venous engorgement of neck, edema of head and neck (SVC syndrome)

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Anterior Mediastinal Mass: Lab Tests/Imaging

answer

• CBC, CXR, chest CT, ECG, echocardiogram, ± flow-vol loop (intra-thoracic obstruction)

question

Anterior Mediastinal Mass: Consults

answer

• Thoracic, cardiac

question

Anterior Mediastinal Mass: Conflict(s)

answer

• Need for GA versus risk of cardiorespiratory collapse

question

Anterior Mediastinal Mass: Optimize/Goals

answer

• Maintain spontaneous ventilation until airway secured or procedure is complete • If airway and/or vascular compression: 1) if possible—awake patient 2) reposition (determine preoperatively which position causes less compression—left/right/prone) 3) rigid bronch and ventilation distal to obstruction 4) sternotomy and surgical elevation of mass off compressed vessels • If requires cardiopulmonary bypass (consider for patients with severe positional symptoms)—establish before induction; will take too long if airway/CVS deteriorates

question

Anterior Mediastinal Mass: Options

answer

• General, local, may require AFOI

question

Anterior Mediastinal Mass: Preop

answer

*Premed: *Blood: surgery dependent *ICU/stepdown bed: yes

question

Anterior Mediastinal Mass: Room Setup (Special Drugs/Monitors)

answer

• Arterial line ± Foley catheter • Difficult airway cart/video laryngoscope

question

Anterior Mediastinal Mass: Induction

answer

• Slow, titrated induction maintaining spontaneous ventilation: sevoflurane, propofol, ketamine • Rigid bronch equipment available (and someone capable of using rigid bronch)

question

Anterior Mediastinal Mass: Maintenance

answer

• Muscle relaxants—manually ventilate to ensure positive pressure ventilation is possible before using

question

Anterior Mediastinal Mass: Emergence

answer

• Ensure ventilation maintained; beware of postanesthetic obstruction

question

Anterior Mediastinal Mass: Disposition/Pain

answer

• PACU, stepdown, ICU as required

question

Anterior Mediastinal Mass: Clinical Pearls

answer

*Anterior mediastinal mass and flow-volume loops: risk of airway collapse during induction supposed to correlate with increase in mid-expiratory plateau when going from upright to supine position. Not borne out with studies! History, physical exam, and chest imaging provide most valuable information.

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