The mediastinum is

the region in the

chest between the
pleural cavities
that contain the
heart and other
thoracic viscera
except the lungs

Definisi
Tumor mediastinum adalah tumor
yang terdapat di dalam mediastinum
yaitu rongga di antara paru-paru
kanan dan kiri yang berisi jantung,
aorta, dan arteri besar, pembuluh
darah vena besar, trakea, kelenjar
timus, saraf, jaringan ikat, kelenjar
getah bening dan salurannya.

Tumor neurogenik
Penatalaksanaan untuk semua tumor
neurogrnik adalah pembedahan, kecuali
neuroblastoma. Tumor ini radisensitif
sehingga pemberian kombinasi
radiokemoterapi akan memberikan hasil
yang baik.
Total reseksi adalah terapi pilihan, jika sel
bersifat ganas atau reseksi tidak komplet
maka radiasi pascabedah sangat dianjurkan.
Pada jenis ganas, misalnya neuroblastoma
yang sulit dibedah, kemoterapi dilakukan
sebelum pembedahan.

 Posterior mediastinal masses rarely cause airway

problems. They predominantly produce effects on the
spinal cord.
Posterior mediastinal masses are traditionally
considered to carry less anesthetic implications.
However, as the tumor enlarges, it often occupies more
than one compartment of mediastinum as there are no
anatomical boundaries between mediastinal
compartments.
With increasing awareness of the risk of acute intraoperative airway obstruction in these patients, life
threatening events occur less frequently in the
operating room.

PH
Pulmonary arterial hypertension (PAH) is
defined as the presence of a mean pulmonary
artery pressure (PAP) that exceeds 25 mm Hg
at rest or 30 mm Hg during exercise.
The goals of anesthetic management are to
provide adequate anesthesia and analgesia for
the surgical procedure, minimize stimuli for
pulmonary vasoconstriction, minimize systemic
cardiovascular depression, and maintain the
ability to treat increases in PVR if they occur.

 PH patients are high risk surgical candidates.

Published series demonstrate a range of
surgical mortalities from a low 4% to high of
24% depending on disease severity and
surgical procedure (1). Surgical and anesthetic
risk should be clearly stated to the patient,
especially for an elective case.
rapid intervention is extremely important in
the treatment of rising PVR, and the
anesthesiologist must maintain the ability to
immediately assist or control ventilation.

 Anesthetic Management
Type of anesthetic: Regional anesthesia is likely the best approach if the
surgery can be performed in this manner (peripheral nerve block or epidural
but not spinal anesthesia); data is limited and retrospective in nature. Martin
et al showed that operative mortality in patients with Eisenmenger
syndrome was 18% with general anesthesia vs. 5% with regional anesthesia
(8). Conversely, Weiss et al conducted a review of obstetric outcomes over
18 years demonstrating similar outcomes using either general or regional
anesthesia (9). For moderate R severe PH, spinal anesthesia is
contraindicated due to chance for abrupt alterations in SVR and preload.
Key Point: Management of either Regional or General Anesthesia with
requires utmost vigilance in this population
Maintain pre-operative medications and continue the prostaglandin infusion,
as even brief infusion interruptions can cause rapid deterioration and death.
For patients taking sildenafil, avoid nitroglycerin and nipride, which can
cause severe hypotension. Outpatient therapy is typically titrated slowly and
carefully, so do not disrupted for elective surgery.

 Monitoring:
Arterial lines are indicated for all but the lowest risk
surgeries. ii)
Central Venous Access: Caution during placement to avoid
inducing arrhythmias. If atrial arrhythmias develop,
cardioversion will avoid the rapid cardiovascular collapse.
Pulmonary Artery Catheters (PAC): The information gained by
this monitor may provide critical information for ventilatory
and inotropic management making it recommended for most
intermediate and all high risk procedures. Caution must be
used when inserting a PAC, which may be more difficult to
place in a PH patient. PAC should not be placed in patients
with Eisenmengers physiology
TEE should be considered if available.

Konsiderasi

Pediatrik
Susp tumor mediastinum
Dextrocardia
Mild TR
PH

Preoperatif
Puasa
Persiapan
penghangat, infus/blood warmer, cairan
dihangatkan
Cek GDs per jam
CVC, arterial line

Kebutuhan cairan
perioperatif
M = 20 cc/jam
Jam I = 25 cc/kg 125 cc
Tiap Jam berikutnya 50 cc/jam +
prdrhn intraop
EBV = 85 x 5 = 425
ABL = 42,5

Induksi

Inhalasi sevoflurane pasang infus

Fentanyl 10 mcg, atracurium 1,5 mg
Intubasi ETT 3,0
Pemasangan arterial line dan CVC

Maintenance
O2, air
Sevoflurane, fentanil, atracurium

Post operatif
PICU
Analgetik post op