Case report
Anesthetic management during anterior mediastinal mass resection in a pediatric patient. A case report
Manejo anestésico para resección de masa mediastínica anterior (MMA) en paciente pediátrico. Descripción de un caso clínico
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A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "39" "paginaFinal" => "43" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Catalán Escudero, M. Uriarte Valiente, P. Morató Robert, H. Souto Romero, I.P. Olavi, E. Martínez García" "autores" => array:6 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Catalán Escudero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Uriarte Valiente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Morató Robert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "H." "apellidos" => "Souto Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "I.P." "apellidos" => "Olavi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "E." "apellidos" => "Martínez García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Anestesiología, Reanimación y Terapia del Dolor, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cirugía Pediátrica, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario de Canarias, Tenerife, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo anestésico para resección de masa mediastínica anterior (MMA) en paciente pediátrico. Descripción de un caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1684 "Ancho" => 1500 "Tamanyo" => 176795 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan: Hypointense tumour lesion in the anterior mediastinum measuring 13.4 × 71.3 × 10.7 cm in its transverse, anteroposterior and craniocaudal axes, respectively.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lymphomas are the third most common malignancy<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the most common cause of anterior mediastinal mass (AMM) in children (46 %–56 % of all mediastinal masses). Previous studies have reported complications in up to 20 % of cases during diagnosis under general anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 6-year-old boy, weight 22 kg, with a 2-month history of dyspnoea and orthopnoea (sleeps sitting). On physical examination: subcostal, intercostal and supraesternal restrictions, baseline SaO<span class="elsevierStyleInf">2</span> 96 %, with 98 % O<span class="elsevierStyleInf">2</span> via nasal prongs at 1.5 l/min, BP 100/61 mmHg; no oedema. Cardiopulmonary auscultation was unremarkable. The chest X-ray (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed a mediastinal mass, probably in the anterior mediastinum. He was admitted to the intensive care unit (ICU) for respiratory support and a complete study.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Following repositioning to the supine position during sedation in the ICU (fentanyl 40 mcg + propofol 60 mg in fractional bolusses) for lumbar puncture and bone marrow biopsy, he presented sudden onset subcostal, intercostal and supraclavicular restrictions and polypnoea with progressive desaturation until pulse oximetry readings were no longer obtained, and bradycardia 70 bpm. He was intubated with rocuronium 20 mg using a 5.5 endotracheal tube and connected to volume-control mechanical ventilation with tidal volume (VT) 180 ml, PEEP 7 cmH<span class="elsevierStyleInf">2</span>O, BR 19 bpm. Given the peak pressure reading of up to 60, he was changed to the prone position. This produced an improvement, and after a few hours we were able to place him in a semi-seated position.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A CT scan (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) performed 3 days later showed the presence of a large AMM measuring 13 × 11 × 7 cm, which exerted a mass effect on mediastinal structures, displacing them posterior and to the left, with no signs of invasion. The mass caused partial compression of the trachea and bronchial bifurcation, and we observed signs of volume overload, with pleuropericardial effusion.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Echocardiography showed a large mass in the anterior mediastinum displacing cardiac structures, and anterior and inferior pericardial effusion 11−15 mm. Ventricular size and contractility were normal.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was intubated in ICU under conscious sedation and mechanical ventilation, and ultrasound-guided biopsy of the mediastinal mass, lumbar puncture and portacath placement was performed in the operating room, without incidents, and the patient was extubated 14 days after admission.</p><p id="par0035" class="elsevierStylePara elsevierViewall">He was diagnosed with type T lymphoblastic lymphoma, and chemotherapy was started. Response was poor, with persistent severe orthopnoea, so surgery for symptomatic treatment was scheduled.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Preoperative auscultation showed isolated crackles. He continued to need oxygen through nasal prongs at 2 lpm during the day and BIPAP and night. A new chest x-ray was performed, which showed no consolidation or pleural effusion, a new echocardiogram showed no pericardial effusion, and a new CT scan with minimal reduction of AMM.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient arrived at the operating room in a seated position (in which he reported he was “able to breathe”, so we define it as his “rescue position”), nasal prongs at 2 lpm, SaO<span class="elsevierStyleInf">2</span> 97 %, and BP 120/60. We performed basic monitoring and checked that the portacath was functioning correctly. Noradrenaline and dobutamine infusion, a syringe of adrenaline and a rigid bronchoscope were prepared if needed, and an ENT team (plan B) and paediatric surgery team prepared for sternotomy were present (plan C).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Anaesthesia was induced with sevoflurane at 8 %, the patient was placed in 50° semi-seated position under spontaneous ventilation without requiring a guedel or support with expired sevoflurane ≥ 6 for 5 min. Intubation was performed with direct laryngoscopy using a n ° 5.5 cuffed endotracheal tube, saturation 98 %, minimum BP of 100/50 mm Hg during induction measured noninvasively every 3 min. The left radial artery and the left central femoral duct were cannulated. Fibreoptic endoscopy was used to rule out collapse of the distal end of the endotracheal tube, and anesthesia was maintained with O<span class="elsevierStyleInf">2</span>/air 40 %/60 %, and 2.5 % sevoflurane.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We then tried to change to supine, and found that there was no increase in work of breathing, and no desaturation or hypotension. If this had not been the case, we would have used the rescue position (plan A), with plan B and C always present and prepared in case of distal tracheal tube collapse or irreversible haemodynamic compromise. Since Vt was maintained at around 160−180 ml, with BR 20–22 bpm in spontaneous ventilation with SaO<span class="elsevierStyleInf">2</span> 98 % and minimum BP of 100/50 mmHg, we continued with a neuromuscular relaxation (NMR) test (with sugammadex4 mg/kg on stand-by, and plan A, plan B and C prepared). We administered 0.3 mg/kg rocuronium, and volume-control mechanical ventilation (vt 200 ml, BR 20 bpm, PEEP 5 cm H<span class="elsevierStyleInf">2</span>O). As were were able to maintain peakP at 18 cm H<span class="elsevierStyleInf">2</span>O and plateauP at 15 cm H<span class="elsevierStyleInf">2</span>O without desaturation or hypotension, we proceeded with the surgery as programmed.</p><p id="par0060" class="elsevierStylePara elsevierViewall">We performed bilateral anterior thoracotomy with transverse sternotomy, followed by tumour resection (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), leaving a fragment adhered to the adventitia of the aorta, trunk of the pulmonary artery and pericardium adjacent to the right atrium. Fluid therapy with crystalloids (500 ml SS and 1000 ml ringer’s lactate).was used throughout the procedure Last blood gas parameters: pH 7.41, pCO<span class="elsevierStyleInf">2</span> 41.2, pO<span class="elsevierStyleInf">2</span> 189, Hto 31.4, Hb 10.2. He did not need transfusion or vasoactive drugs.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Given the possibility of tracheomalacia due to long-term compression, the patient remained intubated and was transferred to the ICU, where an echocardiogram showed adequate cardiac function. He was extubated 20 h after admission and was discharged to the ward with nighttime CPAP.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The anaesthetic management in a patient with an AMM is a major challenge due to the risk of airway obstruction and/or cardiovascular collapse during anaesthesia induction.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Respiratory collapse can occur during induction due to tracheal or bronchial compression and due to a decrease in functional residual capacity associated with the supine position and general anaesthesia, which reflects effects on inspiratory muscle tone, elastic recoil of the chest wall, and cephalad displacement of the diaphragm.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The loss of spontaneous ventilatory activity decreases the transpleural pressure gradient which, under normal conditions, serves to distend intrathoracic airways and prevent collapse.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> NMR can exacerbated this due to loss of tone in the chest wall muscles, neck and supraglottic airway. Positive pressure ventilation increases intrathoracic pressure, which can lead to complete collapse of the trachea, bronchial tubes or major vessels. If the AMM is located at or below the level of the carina, it can be impossible to ventilate or oxygenate the patient, despite endotracheal intubation<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Compression of major cardiovascular structures, a decrease in cardiac index due to an increase in right or left ventricular afterload, or due to the effect on ventricular interdependence can cause haemodynamic compromise. The cardiopulmonary effects of compression can worsen the V/Q mismatch.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">These complications require a multidisciplinary team and good planning based on risk factors for circulatory or respiratory collapse: patients with low risk have no postural symptoms or radiographic evidence of stuctural compression; those at intermediate risk have mild or moderate postural symptoms or tracheal compression > 50 %<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>; high-risk patients have serious symptoms such as cough when supine, ortopnoea (risk of respiratory compromise), superior vena cava syndrome or pericardial effusion (risk of haemodynamic compromise), or radiological signs such as tracheal compression > 50 % or tracheal compression with associated bronchial compression.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Our patient was considered to be t high risk for respiratory compromise due to severe orthopnoea and tracheal compression associated with bronchial compression. The risk of haemodynamic compromise was low, due to the absence of symptoms and pericardial effusion in the last preoperative echocardiogram.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The recommended technique includes step-by-step induction of anaesthesia,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> identifying the position in which symptoms are less severe ("rescue" position) and maintaining the patient in this position, as it helps to maintain the airway permeability and reduces cardiac and vascular compression. Perform a repositioning test before changing position.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">It is also recommended to maintain spontaneous ventilation: performing diagnostic techniques with local anaesthesia and sedation to maintain spontaneous ventilation<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7,9</span></a>; if intubation is unavoidable, awake intubation with fibrobronchoscope is preferable, if the patient cooperates<span class="elsevierStyleSup">10.5</span>; if the patient does not cooperate, perform tracheal intubation under deep inhalational anaesthesia (expired sevoflurane ≥ 6 for 5 min) without the use of relaxants. Muscle relaxants should only be used when absolutely necessary,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and after performing the short-acting relaxant test or having a reversal agent on hand to ensure that the patient can tolerate muscle relaxations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Intraoperative airway compression will require repositioning the patient to the "rescue" position (plan A) or rigid bronchoscopy and ventilation distal to the obstruction (plan B) (rigid bronchoscope and experienced bronchoscopist must be available).<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7,8,10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Severe hypotension may also require a rapid change of position, volume expansion and/or treatment with vasopressors or inotropics. For patients with potentially life-threatening cardiovascular or respiratory compression, the recommended therapy is immediate sternotomy to elevate the mass from the compromised structures (plan C).<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,9,10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Mass effect complications can also occur in the postoperative period, for example, tracheomalacia may occur due to long-term compression of the mass. In this case, it is advisable to consider a period of postoperative ventilation and defer extubation.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In our case, the intervention was planned as follows: plan A was to perform inhalation induction in the patient’s rescue position (semi-seated) and intubation while maintaining spontaneous ventilation. If respiratory compromise occurred plan B (rigid bronchoscope and prepared ENT team) would be set in motion; if this plan failed or the patient presented haemodynamic compromise, plan C (pediatric surgery team for emergency sternotomy) would be set in motion.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Once intubated, a supine test was performed while maintaining spontaneous ventilation (with possible return to rescue position, plan B and plan C prepared). Since ventilation was effective without increased work of breathing, we decided to proceed with the NMR test (with reversal agent prepared, possibility of returning to rescue position, plan B and plan C in place) and mechanical ventilation was initiated. Given the absence of respiratory and haemodynamic alterations, we continued with the intervention as planned</p><p id="par0135" class="elsevierStylePara elsevierViewall">The patient was scheduled for extubation in the ICU.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Safe anaesthesia management requires thorough preoperative evaluation, stratification of the risk of respiratory and/or haemodynamic compromise, risk-based anaesthesia planning, and a multidisciplinary approach. Patients with AMM with symptoms of respiratory or cardiovascular compression are included in the high-risk group for NMR. The risk of cardiorespiratory collapse can be reduced by performing step-by-step anaesthesia, inducing in a rescue position, maintaining spontaneous ventilation, performing the repositioning test before proceeding with the intervention, performing a muscle relaxation test if NMR is unavoidable. Before performing either test, plan A, B and C must be available to reverse the collapse, clear the obstruction or elevate the mass if necessary.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1294719" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1195616" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1294720" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1195617" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-02-06" "fechaAceptado" => "2019-09-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1195616" "palabras" => array:3 [ 0 => "Anterior mediastinal mass" 1 => "Anesthetic management" 2 => "Pediatric patient" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1195617" "palabras" => array:3 [ 0 => "Masa mediastínica anterior" 1 => "Manejo anestésico" 2 => "Paciente pediátrico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complications induced by general anesthesia (GA) and neuromuscular relaxation (NMR) in anterior mediastinal mass (AMM) resection can be serious, especially when there are signs of compression of the airway or large vessels (dyspnea, orthopnea, etc.) (1). It is preferable to perform the procedure in spontaneous ventilation to avoid respiratory or cardiovascular collapse due to the supine position or to loss of negative intrathoracic pressure with GA and NMR. If the supine position and NMR are unavoidable, procedures should be performed in a step-wise manner, and rescue strategies should be prepared (rescue position, bronchoscope, sternotomy). Correct preoperative evaluation, adequate planning, and a multidisciplinary approach will ensure patient safety. We present the case of a child with a history of severe orthopnea and a diagnosis of AMM and lymphoblastic lymphoma (respiratory arrest and cardiovascular collapse during sedation for lumbar puncture and bone marrow biopsy) that did not respond to medical treatment and required resection surgery under GA with NMR.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las complicaciones inducidas por anestesia general (AG) y relajación neuromuscular (RNM) en cirugía de MMA pueden ser graves sobretodo si existe clínica de compresión de la vía aérea o grandes vasos (disnea, ortopnea…) (1). Es preferible realizar el procedimiento en ventilación espontánea para evitar el colapso respiratorio o cardiovascular por decúbito supino o por pérdida de la presión negativa intratorácica con la AG y RNM. En caso de precisar decúbito supino y RNM se realizarán paso a paso con técnicas de rescate preparadas (posición de rescate, broncoscopio, esternotomía). Una correcta evaluación preoperatoria, adecuada planificación y abordaje multidisciplinar permiten realizar una anestesia y cirugía seguras. Presentamos el caso de un niño con antecedentes de ortopnea severa con diagnóstico de MMA, linfoma linfoblástico (parada respiratoria y colapso cardiovascular en sedación para punción lumbar y biopsia de médula ósea) que no responde a tratamiento médico y precisa cirugía de resección bajo AG con RNM.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Catalán Escudero P, Uriarte Valiente M, Morató Robert P, Souto Romero H, Olavi IP, Martínez García E. Manejo anestésico para resección de masa mediastínica anterior (MMA) en paciente pediátrico. Descripción de un caso clínico. Rev Esp Anestesiol Reanim. 2020;67:39–43.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 734 "Ancho" => 750 "Tamanyo" => 37364 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1684 "Ancho" => 1500 "Tamanyo" => 176795 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan: Hypointense tumour lesion in the anterior mediastinum measuring 13.4 × 71.3 × 10.7 cm in its transverse, anteroposterior and craniocaudal axes, respectively.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 919 "Ancho" => 900 "Tamanyo" => 109887 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mediastinal mass.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A multidisciplinary approach to the management of anterior mediastinal masses in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:5 [ 0 => "S.N. 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