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{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
LMA
| lines_access = PIV x1-2
| monitors = Standard
| considerations_preoperative = PIV in non-operative arm
| considerations_intraoperative =
| considerations_postoperative = PONV
}}


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<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!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<!-- 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
** 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. --> ===
=== 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. --> ===
* 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>. 
== Intraoperative management ==
=== 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
=== 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. --> ===
* 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<!-- 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. --> ===
* PONV prophylaxis (females are more susceptible to PONV)
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* PACU
=== 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. --> ===
* PONV
* Lymphedema
* Seroma
* Pneumothorax
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable"
|+
!
!Total mastectomy
!Modified radical mastectomy
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
== References ==
[[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
In development
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

  1. ↑ 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.

Top contributors: Barrett Larson, Eeshwar Chandrasekar, Chris Rishel and huckfinne@gmail.com

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