Mastectomy

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
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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

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.

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