Case ReportAnesthetizing a child for a large compressive mediastinal mass with distraction techniques and music therapies as the sole agents

•Thorough assessment of feasibility through discussion with the family, child, and medical team.•Extensive communication and planning with the entire perioperative team are paramount to success.•Topical local anesthetic cream should be applied 45 minutes prior to procedure for maximal benefit.•Distraction techniques with audiovisual aids to increase engagement.•Utilization of child life and behavioral health support when possible.

Anesthetic management of the child with an anterior mediastinal mass is challenging. The surgical/procedural goal typically is to obtain a definitive tissue diagnosis to guide treatment; the safest approach to anesthesia is often one that alters cardiorespiratory physiology the least. In severe cases, this may translate to little or no systemic sedatives/analgesics. Distraction techniques, designed to shift attention away from procedure-related pain (such as counting, listening to music, non-procedure-related talk), may be of great benefit, allowing for avoidance of pharmaceuticals. In this report, we present an approach in children where the anesthetic risk is deemed excessive.