Wilms Tumor Resection (Pediatric)
Patient phenotype
Toddler/young child (typical age 2-5). Abdominal mass, hematuria, HTN. May have post-chemo (vincristine, dactinomycin, doxorubicin — cardiotoxicity). Some with IVC tumor extension.
Procedure
Open transabdominal nephrectomy + LN sampling. Tumor often very large in small abdomen. ~3-5 hours. May extend to IVC requiring caval cross-clamp.
Anesthetic plan
Pediatric GETA. Multiple PIVs (16-18g for size). A-line + CVC for fluid + blood. Type & cross 2 units. Avoid hypothermia.
Setup
- ·Pediatric circuit, warmed
- ·A-line
- ·Multiple large PIVs
- ·CVC if IVC involvement or expected long case
- ·Type & cross 2 units PRBC
- ·Forced air warmer + fluid warmer
- ·Foley
- ·Caudal block or epidural for postop
Biggest concerns by phase
Chemo cardiotoxicity
Doxorubicin cumulative dose-dependent CM. Recent echo. Continue beta-blocker + ACE if on. Vincristine: peripheral neuropathy noted.
Hypertension + paraneoplastic
Renin-mediated HTN common. Workup for catecholamine-secreting tumor (overlap with neuroblastoma) — plasma metanephrines if any concern.
Tumor manipulation + IVC compression
Large tumor manipulation can suddenly drop venous return → BP plunge. Communicate with surgeon. Reserve fluid + pressors.
IVC tumor thrombus + caval cross-clamp
10% of Wilms have IVC extension. Caval clamp = profound preload drop. Often requires CPB or VV bypass for high-level extension. Pre-op imaging dictates planning.
Major fluid shifts + transfusion
Large tumor + extensive dissection = significant blood loss. Goal-directed. PRBC available + warm.
ICU disposition + analgesia
Most go to ICU. Caudal/epidural for analgesia. Multimodal.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
3-yo, 14 kg, R Wilms tumor with imaging-confirmed IVC extension to renal vein, prior 2 cycles of vincristine + dactinomycin. Open R nephrectomy. Plan?
What an examiner probes for
- ▹Recent echo + cardiac assessment
- ▹A-line + CVC + multiple PIVs
- ▹Anticipates IVC manipulation hypotension
- ▹Transfusion preparedness
- ▹Caudal/epidural analgesia
Sources
- Coté Peds Anesthesia 6e Ch 26
- COG Renal Tumor Protocols
Anatomy reference
Sourced reference images. 4 matches for "kidney renal abdomen".
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