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| anesthesia_type = General
| anesthesia_type = General
| airway = ETT vs. LMA
| airway = ETT vs. LMA
| lines_access = PIV
| lines_access = PIV x 1-2
| monitors = Standard monitors
| monitors = Standard monitors
| considerations_preoperative = Place IV in non-operative extremity
| considerations_preoperative = Place IV in non-operative extremity
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|-
|-
|Respiratory
|Respiratory
|
|Patients receiving radiation therapy to the chest/thorax can have respiratory compromise
|-
|-
|Gastrointestinal
|Gastrointestinal
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=== 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. --> ===


* 20g PIV (non-operative extremity)
* 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. --> ===
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* 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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|+
|+
!
!
!Variant 1
!Total mastectomy
!Variant 2
!Modified radical mastectomy
|-
|-
|Unique considerations
|Unique considerations

Revision as of 19:55, 25 May 2021

Mastectomy
Anesthesia type

General

Airway

ETT vs. LMA

Lines and access

PIV x 1-2

Monitors

Standard monitors

Primary anesthetic considerations
Preoperative

Place IV in non-operative extremity

Intraoperative
Postoperative
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.
Respiratory 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.