Difference between revisions of "Mastectomy"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = General | | anesthesia_type = General | ||
| airway = ETT | | airway = ETT | ||
| lines_access = PIV | LMA | ||
| monitors = Standard | | lines_access = PIV x1-2 | ||
| considerations_preoperative = | | monitors = Standard | ||
| considerations_preoperative = PIV in non-operative arm | |||
| considerations_intraoperative = | | considerations_intraoperative = | ||
| considerations_postoperative = | | considerations_postoperative = PONV | ||
}} | }} | ||
| Line 23: | Line 24: | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
|Chemotherapy (ex. anthracyclines) can cause cardiomyopathy that is often irreversible. Use of trastuzamab can cause reversible decrease in LV function. | |Chemotherapy (ex. anthracyclines) can cause cardiomyopathy that is often irreversible. | ||
Use of trastuzamab can cause reversible decrease in LV function. | |||
|- | |- | ||
| | |Pulmonary | ||
| | |Patients receiving radiation therapy to the chest/thorax can have respiratory compromise | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| Line 46: | Line 48: | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* CBC with diff and platelet count | * CBC with diff and platelet count | ||
** May have anemia or thrombocytopenia due to chemo | |||
* EKG | |||
* Consider echo | |||
** May have cardiomyopathy due to chemotherapy | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* Consider acetaminophen, gabapentin and/or celecoxib | |||
* Anxiolysis, as needed | |||
* ERAS protocol | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
* Consider paravertebral blocks | * Consider paravertebral blocks, transversus abdomens plane (TAP) block, or thoracic epidural | ||
* Studies have shown a trend towards increasing utilization of peripheral nerve blocks (PNB) for mastectomy. As of 2018, ~13% of cases involved a PNB according to the National Anesthesia Clinical Outcomes Registry<ref>{{Cite journal|last=Lam|first=Stephanie|last2=Qu|first2=Helena|last3=Hannum|first3=Margaret|last4=Tan|first4=Kay See|last5=Afonso|first5=Anoushka|last6=Tokita|first6=Hanae K.|last7=McCormick|first7=Patrick J.|date=2021-05-24|title=Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018|url=https://journals.lww.com/anesthesia-analgesia/Abstract/9900/Trends_in_Peripheral_Nerve_Block_Usage_in.56.aspx|journal=Anesthesia & Analgesia|language=en-US|pages=10.1213/ANE.0000000000005368|doi=10.1213/ANE.0000000000005368|issn=0003-2999}}</ref>. | * Studies have shown a trend towards increasing utilization of peripheral nerve blocks (PNB) for mastectomy. As of 2018, ~13% of cases involved a PNB according to the National Anesthesia Clinical Outcomes Registry<ref>{{Cite journal|last=Lam|first=Stephanie|last2=Qu|first2=Helena|last3=Hannum|first3=Margaret|last4=Tan|first4=Kay See|last5=Afonso|first5=Anoushka|last6=Tokita|first6=Hanae K.|last7=McCormick|first7=Patrick J.|date=2021-05-24|title=Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018|url=https://journals.lww.com/anesthesia-analgesia/Abstract/9900/Trends_in_Peripheral_Nerve_Block_Usage_in.56.aspx|journal=Anesthesia & Analgesia|language=en-US|pages=10.1213/ANE.0000000000005368|doi=10.1213/ANE.0000000000005368|issn=0003-2999}}</ref>. | ||
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=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* | * PIV x 1-2 (non-operative extremity) | ||
* Place BP cuff on non-operative extremity | * Place BP cuff on non-operative extremity | ||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Standard induction | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
| Line 72: | Line 84: | ||
* Repositioning may be required | * Repositioning may be required | ||
* Avoid brachial plexus stretch | * Avoid brachial plexus stretch | ||
* Repositioning may be required if reconstruction is also being done (i.e. latissimus doors flap) | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* Standard maintenance | |||
* Surgeon may prefer no paralytic for the axillary direction | |||
* Maintain normovolemia -goal-directed fluid management | |||
* Maintain normothermia - warming blanket | |||
* Avoid anemia and blood transfusions | |||
* Watch out for potential pneumothorax with deep surgical exploration | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* PONV prophylaxis (females are more susceptible to PONV) | |||
== Postoperative management == | == Postoperative management == | ||
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=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Emphasize multimodal pain management | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
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|+ | |+ | ||
! | ! | ||
! | !Total mastectomy | ||
! | !Modified radical mastectomy | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| Line 132: | Line 156: | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
<references /> | |||
[[Category:General surgery]] | |||
[[Category:Breast surgery]] | |||
Latest revision as of 22:23, 4 April 2022
Mastectomy
| Anesthesia type |
General |
|---|---|
| Airway |
ETT LMA |
| Lines and access |
PIV x1-2 |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative |
PIV in non-operative arm |
| Intraoperative | |
| Postoperative |
PONV |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A total mastectomy (simple mastectomy) refers to the complete removal of breast tissue. A modified radical mastectomy refers to the removal of the breast and the corresponding axillary lymph nodes.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Chemotherapy (ex. anthracyclines) can cause cardiomyopathy that is often irreversible.
Use of trastuzamab can cause reversible decrease in LV function. |
| Pulmonary | Patients receiving radiation therapy to the chest/thorax can have respiratory compromise |
| Gastrointestinal | |
| Hematologic | Chemotherapy can cause anemia and thrombocytopenia. |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
- CBC with diff and platelet count
- May have anemia or thrombocytopenia due to chemo
- EKG
- Consider echo
- May have cardiomyopathy due to chemotherapy
Operating room setup
Patient preparation and premedication
- Consider acetaminophen, gabapentin and/or celecoxib
- Anxiolysis, as needed
- ERAS protocol
Regional and neuraxial techniques
- Consider paravertebral blocks, transversus abdomens plane (TAP) block, or thoracic epidural
- Studies have shown a trend towards increasing utilization of peripheral nerve blocks (PNB) for mastectomy. As of 2018, ~13% of cases involved a PNB according to the National Anesthesia Clinical Outcomes Registry[1].
Intraoperative management
Monitoring and access
- PIV x 1-2 (non-operative extremity)
- Place BP cuff on non-operative extremity
Induction and airway management
- Standard induction
Positioning
- Supine
- Ipsilateral arm may be prepped into field
- Repositioning may be required
- Avoid brachial plexus stretch
- Repositioning may be required if reconstruction is also being done (i.e. latissimus doors flap)
Maintenance and surgical considerations
- Standard maintenance
- Surgeon may prefer no paralytic for the axillary direction
- Maintain normovolemia -goal-directed fluid management
- Maintain normothermia - warming blanket
- Avoid anemia and blood transfusions
- Watch out for potential pneumothorax with deep surgical exploration
Emergence
- PONV prophylaxis (females are more susceptible to PONV)
Postoperative management
Disposition
- PACU
Pain management
- Emphasize multimodal pain management
Potential complications
- PONV
- Lymphedema
- Seroma
- Pneumothorax
Procedure variants
| Total mastectomy | Modified radical mastectomy | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Lam, Stephanie; Qu, Helena; Hannum, Margaret; Tan, Kay See; Afonso, Anoushka; Tokita, Hanae K.; McCormick, Patrick J. (2021-05-24). "Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018". Anesthesia & Analgesia: 10.1213/ANE.0000000000005368. doi:10.1213/ANE.0000000000005368. ISSN 0003-2999.