Year : 2009  |  Volume : 12  |  Issue : 1  |  Page : 63--66

Anaesthetic management of a child presenting with intrapericardial teratoma compressing the airway and the heart


Indrani Hemant Kumar1, V Shrote2, Hemant Kumar2,  
1 TNMC and BYL Nair Hospital, 1003A, Lady Ratan Towers, D S Marg, Worli, Mumbai, India
2 Superspeciality Hospital, Nagpur, India

Correspondence Address:
Indrani Hemant Kumar
1003A, Lady Ratan Towers, D S Marg, Worli, Mumbai - 400 018
India

Abstract

Intrapericardial tumours can cause cardiac compromise either from pericardial effusion producing cardiac tamponade or from the mass obstructing the outflow from the heart or both. Respiratory embarrassment may also be present if the mass compresses the trachea or the main stem bronchus. A 1-month-old child presented in the emergency needing prompt measures to relieve compressive symptoms. Successful anaesthetic and surgical management led to uneventful recovery. Histopathology of the mass revealed a rarely occurring intrapericardial teratoma. After surgical removal, the child had clinical follow-up for more than a year. Intrapericardial teratoma is a rare entity that presents a diagnostic and therapeutic challenge. The authors describe the case of a 1-month-old male child with this condition who was successfully managed by resection of the mass.



How to cite this article:
Kumar IH, Shrote V, Kumar H. Anaesthetic management of a child presenting with intrapericardial teratoma compressing the airway and the heart.Ann Card Anaesth 2009;12:63-66


How to cite this URL:
Kumar IH, Shrote V, Kumar H. Anaesthetic management of a child presenting with intrapericardial teratoma compressing the airway and the heart. Ann Card Anaesth [serial online] 2009 [cited 2021 Sep 25 ];12:63-66
Available from: https://www.annals.in/text.asp?2009/12/1/63/45016


Full Text

Intra-pericardial teratoma is a rare, congenital, condition. Usually, these are pedunculated, primary cardiac tumours. [1],[2] They may be diagnosed in utero or soon after birth because of their association with massive pericardial effusion, [3] cardiac compression, and severe cardio-respiratory distress. [1],[2],[4] The tumour is generally benign and early surgical removal is curative. The authors report successful excision of a teratoma in a 30-day-old child.

 Case Report



A month-old male child, weighing 3.5 kg, was admitted to the author's institute with respiratory distress. The child had fever and cough for 9 days in addition to dyspnoea. Physical examination showed pallor, thready pulse, elevated jugular venous pressure, fever and muffled heart sounds. There was indrawing of the chest cavity with inspiration. There was no paedal oedema, puffiness of face or engorged veins over the chest wall or upper arm. Liver and spleen were palpable. The heart rate was over 160/min and the systolic blood pressure 70mm Hg. The respiratory rate was 50/min. The oral intake in the past few days was reported to be less. Electrocardiogram showed sinus tachycardia with low voltage complexes. Chest X-ray revealed cardiomegaly with a cardiothoracic ratio of 0.80 [Figure 1]. Transthoracic echo revealed a small pericardial effusion and dense echogenic layers anterior to aorta and right atrium. A computed tomography (CT) of thorax [Figure 2] showed n ill defined heterogeneous mass lesion of size 4.5 3.4 3.2 cm in the pericardial cavity on the right side. The CT scan revealed that the mass was abutting the pericardium anteriorly, indenting the right atrium posteroinferiorly, reaching up to the level of aortic arch superiorly and abutting the pericardium of right side laterally. Posteromedialy, it was in close relation to the SVC, ascending aorta and right pulmonary trunk, insinuating between the superior vena cava and ascending aorta. The thymus was displaced anterosuperiorly. The lower part of the trachea, carina and proximal part of the main bronchi were compressed and the oesophagus was shifted to the right side. Consolidating changes were observed on the proximal segment of upper lobe, apical, posterobasal, medial and lateral basal segments of the right lobes of the lung. There was no time to perform serum alpha fetoprotein levels. An intrapericardial tumour with pericardial effusion was diagnosed.

The child was scheduled for removal of the intrapericardial tumour. The risks involved were airway obstruction and worsening of the cardiac tamponade. An informed consent was given by the mother. Preoperative pericardiocentesis was not performed because the potential benefits of it were thought to be small, considering the small size of the pericardial effusion. If cardiovascular collapse or airway obstruction occurred during induction, it was decided to proceed quickly with sternotomy and immediately drain the pericardial effusion and pull up the tumour. Sedative premedication was avoided. The preoperative heart rate was 168 beats per minute and systolic blood pressure was 72 mm Hg. The SpO 2 before induction was 90%. After administration of 100% Oxygen by mask, SpO 2 rose to 97%. An infusion of Paediatric electrolyte solution was started. The patient received I V atropine 0.02 mg/kg and efcorlin 10 mg. Anaesthesia was induced with nitrous oxide, oxygen and sevoflurane 5% with the child breathing spontaneously. Gentle positive pressure ventilation was given to ascertain if ventilation was possible; the patient could be ventilated. There was no critical cardiorespiratory event in the form of airway collapse or hypotension, succinylcholine 6 mg intravenous was administered and the trachea was intubated with a 3.5 mm Portex endotracheal tube. General anaesthesia was maintained with nitrous oxide, oxygen, sevoflurane, 6mg tramadol and 2 mg increments of atracurium. A central venous line and an arterial line were established. The pericardium was opened after a midsternotomy and nearly 100 ml of pericardial fluid was drained. The tumour was removed in toto. Teratoma was diagnosed by histopathological exam of the excised specimen [Figure 3],[Figure 4],[Figure 5]. A caudal epidural catheter was placed at the end of surgery and 3.5 cc of 0.125% sensorcaine was given for pain relief. The blood gas values showed mild respiratory acidosis. The child was electively ventilated overnight and extubated the following morning. The oxygen saturations were maintained between 99-100% during the intraoperative and postoperative period. The child was observed for 2 more days in the intensive care where he received epidural 'top ups' of 3.5 cc of 0.125% sensorcaine on the first day and epidural tramadol 5 mg on the second day. The child made an uneventful recovery and was subsequently transferred to the ward.

 Discussion



The incidence of congenital intrapericardial teratoma is about 0.0017% to 0.003%. [5] They are usually benign and frequently associated with massive pericardial effusion, cardiac compression, and severe cardiorespiratory distress, noticed shortly after birth. Histologically, they contain endodermic, mesodermic, and neuroectodermic germinal layers. [6],[7],[8] The newborns may have elevated alpha-fetoprotein levels. [9],[10]

Two-dimensional echocardiography is considered to be the one of the easiest and best diagnostic imaging modality for primary cardiac tumours, but magnetic resonance imaging may have advantages with large tumours in defining the relationship of the tumour to adjacent structures. [1] In the patient presented in this report, the CT scan served as an important aid in the preoperative assessment of the intrapericardial mass. Sedative premedication is avoided as the tumour can cause an intra-thoracic obstruction, especially if the tumour, which is already causing cardiac compression, is lying on the trachea or a major airway. [11],[12]

Intrapericardial tumours pose a continuing challenge to the anaesthesiologists and surgeons alike. The anaesthesiologists should expect airway obstruction or a haemodynamic collapse during induction of anaesthesia, which is unresponsive to any treatment except immediate debulking of the tumour. [11],[12] A rescue cardiopulmonary bypass would be of no use as the tumour usually is anteriorly placed. Hence, the cardiovascular surgeon should be ready to proceed with median sternotomy and drain the effusion and pull up the tumour if required immediately [12] during this critical event. Use of epidural analgesia with local anaesthetics in the post-operative period is useful in neonates who are prone to apnoea or have blunted ventilatory responses. [13]

In this patient, the teratoma was anchored to the ascending aorta and was compressing the right atrium. A definitive diagnosis was established by thoracotomy, resection and microscopic examination of the specimen. Surgical removal is not only curative but also potentially lifesaving because these lesions often become fatal if not promptly excised. The long-term prognosis is good.

References

1Sumner TE, Crowe JE, Klein A, McKone RC, Weaver RL. Intrapericardial teratoma in infancy. Pediatr Radiol 1980;10:51-3.
2Arciniegas E, Hakimi M, Farooki ZQ, Green EW. Intrapericardial teratoma in infancy. J Thorac Cardiovasc Surg 1980:79:306-11.
3Laquay N, Ghazouani S, Vaccaroni L, Vouhι P. Intrapericardial teratoma in newborn babies. Eur J Cardiothorac Surg 2003;23:642-4.
4Ragupathy R, Nemeth L, Kumaran V, Rajamani G, Krishnamoothy P. Successful surgical management of a prenatally diagnosed intrapericardial teratoma. Pediatr Surg Int 2003;19:737-9.
5Allen HD, Moss AJ. Moss and Adams' heart disease in infants, children, and adolescents: Including the fetus and young adult. Lippincott Williams and Wilkins; 2007. ISBN 0781786843, 9780781786843; p. 1479.
6Marianeschi SM, Seddio F, Abella RF, Colagrande L, Iorio FS, Marcelletti CF. Intrapericardial teratoma in a newborn: A case report. J Card Surg 1999;14:169-71.
7Tollens T, Casselman F, Devlieger H, Gewillig MH, Vandenberghe K, Lerut TE, et al . Fetal cardiac tamponade due to an intrapericardial teratoma. Ann Thorac Surg 1998;66:559-60.
8Vaideeswar P, Deshpande JR, Sivaraman A Intrapericardial teratoma: A report of two Cases. Indian J Pathol Microbiol 2000;43:351-2.
9Roy N, Blurton DJ, Azakie A, Karl TR. Immature intrapericardial teratoma in a newborn with elevated alpha- fetoprotein. Ann Thorac Surg 2004;78:e6-8.
10Carachi R, Campbell PE, Chow CW, Mee BB. Alpha-feto-protein-(AFP-)- secreting intra-pericardial teratoma--report of a case diagnosed on CT scanning. Z Kinderchir 1986;41:369-70.
11Slinger PA, Karsli CB. Management of the patient with a large anterior mediastinal mass: Recurring myths. Thorac Anaesth Curr Opin Anaesthesiol 2007;20:1-3.
12Goh MH, Liu XY, Goh YS. Anterior mediastinal masses: An anaesthetic challenge. Anaesthesia 1999;54:670-4.
13Murthy BV, Pandya KS, Booker PD, Murray A, Lintz W, Terlinden R. Pharmacokinetics of tramadol in children after i.v. or caudal epidural administration. Br J Anaesth 2000;84:346-9.