Slide 1

The mediastinum is the region in the chest between the pleural cavities that contain the heart and other thoracic viscera except the lungs

DefinisiTumor 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 intra-operative airway obstruction in these patients, life threatening events occur less frequently in the operating room.PHPulmonary 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 physiologyTEE should be considered if available.

Konsiderasi Pediatrik Susp tumor mediastinumDextrocardia Mild TRPH

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 ccTiap Jam berikutnya 50 cc/jam + prdrhn intraopEBV = 85 x 5 = 425 ABL = 42,5 Induksi Inhalasi sevoflurane pasang infus Fentanyl 10 mcg, atracurium 1,5 mgIntubasi ETT 3,0Pemasangan arterial line dan CVCMaintenance O2, airSevoflurane, fentanil, atracurium

Post operatifPICUAnalgetik post op