One of the more challenging cases facing a pediatric anesthesiologist is the management of patients presenting with an anterior mediastinal mass (AMM). Patients with an AMM may have severe cardiopulmonary compromise that can be exacerbated when undergoing general anesthesia. Several case reports have documented cardiopulmonary collapse during induction or maintenance of general anesthesia and even for procedures done without anesthesia. Despite increased understanding and management of these patients, perioperative complications, defined as anything from transient decreases in blood pressure correcting with fluids or mild airway obstruction requiring no intervention, to complete cardiopulmonary collapse, are still estimated to occur during 9% to 20% of anesthetic procedures. The purpose of this review article is to provide foundational knowledge of the anatomy and physiology of a patient with an AMM, with particular emphasis on the pediatric patient. It will assist in recognizing presenting signs and symptoms and discuss the appropriate preoperative testing, which together can help assess perioperative risk and determine the appropriate anesthetic management plan for the patient's safety and comfort.
Dentists are expected to deliver safe and pain-free dental procedures after they graduate from dental school. This includes using local anesthetics and sedative drugs that may be associated with side effects and complications that can lead to crisis situations. This study postulated that teaching medical crisis management to dental residents and assistants using human patient simulation (HPS) would improve their conidence in managing crisis situations in the real world. Four medical crisis scenarios were designed and programmed into a pediatric simulator. The scenarios included anaphylaxis, laryngospasm during procedural sedation, sedative medication overdose, and multiple drug interaction with cardiac arrhythmia. The simulation room was outitted with an authentic dental operatory and emergency equipment to enhance the realism. One irst-or second-year pediatric dentistry resident and a staff dental assistant were assigned as a team to participate in each ten-minute scenario followed by a debrieing session. At the end of the sessions, the participants completed an anonymous survey regarding the simulation experience. There were a total of twenty-four participants, 91.7 percent of whom felt that HPS was a good tool for learning medical crisis and that they will be more conident in managing a similar situation in the dental ofice after this experience. A majority of the participants felt that using HPS as a tool to teach crisis management is an acceptable and valuable technique to help improve their conidence in managing crisis situations that may occur in dental ofices.
Background: Mediastinal masses in children may present with compression of the great vessels and airway. An interdisciplinary plan for rapid diagnosis, acute management, and treatment prevents devastating outcomes and optimizes care. Emergency pretreatment with steroids or radiation is more likely to be administered when care is variable, which may delay and complicate diagnosis and treatment. Strategies to standardize care and expedite diagnosis may improve acute patient safety and long-term outcomes. Aims:The aim of this quality improvement project was to decrease time from presentation to diagnostic biopsy for children with an anterior mediastinal mass by 50% over 3 years within a tertiary healthcare system. Methods: This quality improvement project involved a single center with data collected and analyzed retrospectively and prospectively for 71 patients presenting with anterior mediastinal mass between February 2008 and January 2018. The Model for Improvement was utilized for project design and development of a driver diagram and smart aim. An algorithm was implemented to facilitate communication between teams and standardize initial care of patients with mediastinal masses. The algorithm underwent multiple Plan-Do-Study-Act (PDSA) cycles. Data were collected before and after algorithm implementation and between each PDSA cycle. The primary outcome measure included time from presentation to biopsy, which was monitored with a statistical process control chart. Several process measures were evaluated with Student's t-tests including administration of emergency pretreatment.Results: Nineteen patients preintervention and 52 patients postintervention were included in the analysis. Time from presentation to biopsy significantly decreased from 48 h at baseline to 24 h postimplementation. Although not statistically significant, emergency pretreatment decreased from a baseline of 26.3% to 6.7% postimplementation. Conclusion:Implementation of a diagnostic and management algorithm coordinating care among multidisciplinary teams significantly reduced time to biopsy for children presenting with mediastinal mass and may result in decreased use of emergent pretreatment.
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