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Hızır Okuyan, Cihan Altın, Okan Arıhan1 Department of Cardiology, Yenimahalle State Hospital, 1Department of Physiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey Address for correspondence: Dr. Hızır Okuyan, Yenibatı Mah, 2026 Cad, PK: 06370 Batıkent, Yenimahalle, Ankara, Turkey. E-mail:
[email protected]
REFERENCES 1. Okuyan H, Altin C, Arihan O. Anaphylaxis during intravenous administration of amiodarone. Ann Card Anaesth 2013;16:229‑30. 2. Lloyd‑Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: The Framingham Heart Study. Circulation 2004;110:1042‑6. 3. Kannel WB, Benjamin EJ. Status of the epidemiology of atrial fibrillation. Med Clin North Am 2008;92:17‑40. 4. European Heart Rhythm Association, European Association for Cardio‑Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, et al. Guidelines for the management of atrial fibrillation: The task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369‑429. 5. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719‑47.
Figure 1: Axial contrast-enhanced computed tomography of the chest shows the heterogeneously enhancing right paravertebral lesion (M) extending anteriorly. The arrow shows the displacement and compression of the vessel and Trachea (T). The esophagus depicted in the original case report is marked as E. The actual position of the esophagus is marked as small arrows (The figure is taken from the indexed case report and published with the permission of Medknow publications, India)
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In response to “Posterior mediastinal mass: Do we need to worry much ?” The Editor, We would like to put forth our view in response to “Posterior mediastinal mass: Do we need to worry much?” by Lalwani et al. [1] The article presents interesting facts. It introduces to the reader by stating that posterior mediastinal mass carries less anesthetic implications. The authors mention that these masses, with progression, can compress the vital structures including the trachea and the bronchus. The index 72
Figure 2: Axial contrast-enhanced computed tomography of the chest in an otherwise normal study. Note the contour and position of the trachea (T) and the esophagus (E)
patient has initially presented with pain, weakness and grade 1 dyspnea with hoarseness of voice. With the mention of the absence of orthopnea, non-productive cough, stridor etc. the authors, it seems, presumed that there is no airway compression. However, the given axial computed tomography image [Figure 1] shows evidence of airway compression. The scan clearly shows that the mass has started from the paravertebral region and extended anteriorly to push the esophagus and the trachea anteriorly. On comparison with a normal cross section image of the chest at this level, the displacement and loss of contour of the airway secondary to the compression by the mass is evident [Figure 2]. Even though, in the patient, there is lack of clinical evidence of the airway compression, the objective imaging evidence of airway compression should have warned Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
[Downloaded free from http://www.annals.in on Wednesday, May 9, 2018, IP: 37.150.19.159] 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
