Anterior mediastinal mass with SVC obstruction for node biopsy16-year-old boy, 58 kg, for urgent excision biopsy of a left supraclavicular node to diagnose a mass in the anterior mediastinum

The patient

The examiner asks

Answer aloud, then press Show.

1. Consider

   What are your concerns?

   Show the answerHide the answer

   • A 16-year-old with a big anterior mediastinal tumour obstructing his SVC, for urgent node biopsy. Patient
   • As a teenager his airway is softer, and most anaesthetic deaths here have been in children.
   • He can't lie flat, so the mass may close his airway once he is asleep. Disease
   • His tracheal narrowing sits just above the carina, past where a tube reaches. Airway
   • His SVC is compressed and he has an effusion, so his circulation is at risk too. Disease

2. Prepare

   How do you assess his risk?

   Show the answerHide the answer

   • Symptoms graded: he cannot tolerate supine at all, which is the severe grade. Disease
   • CT shows 55% tracheal narrowing; over 50% in a child means general anaesthesia is unsafe. Airway
   • Echo for the effusion and any compression of the heart or pulmonary artery. Disease
   • Mild symptoms wouldn't reassure me; symptoms don't predict how bad collapse will be under anaesthesia.
   • I ask him which position eases his breathing, since that is my rescue position. Airway

3. Prepare

   What do you discuss with the team before the biopsy?

   Show the answerHide the answer

   • Tissue from outside the chest first: this neck node under local anaesthesia. Surgery
   • Steroids before biopsy may shrink the mass but can hide the diagnosis; oncology decides. Disease
   • Cannulas in his legs, because arm veins drain into the blocked SVC.
   • Arterial line, and only modest fluid; too much worsens SVC obstruction.
   • Rigid bronchoscope and surgeon in the room; ECMO team aware, not relied on for rescue. Airway

4. Plan

   If he does need anaesthesia, how will you do it?

   Show the answerHide the answer

   • Sitting up, local anaesthetic infiltration, and light dexmedetomidine so he keeps breathing. Airway
   • If deeper is needed, sevoflurane or titrated ketamine, keeping spontaneous breathing throughout.
   • No relaxant unless I've first proved I can ventilate him by hand.
   • Flat supine is never required for this; he stays in his best position.
   • He is watched closely in recovery; airway obstruction now often happens after surgery. After surgery

5. Crisis

   Under sedation he is laid flat for draping. SpO2 falls to 82%, BP to 70/40, and he is struggling to breathe. What do you do?

   Show the answerHide the answer

   • Sit him straight back up and stop the sedation; 100% oxygen. Crisis
   • Not better: turn him lateral or prone, to his position of relief.
   • Let him wake up fully if he isn't recovering; consciousness is protecting his airway.
   • Total obstruction: rigid bronchoscope past the mass to ventilate below it.
   • Phenylephrine 50–100 mcg through a leg cannula for his pressure while positioning works.
   • Once he is safe, the biopsy proceeds sitting under local, or stops for oncology to replan. After surgery