Anaesthesia for Breast Surgery PDF (2003)

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/30966949 Anaesthesia for breast surgery Article in Continuing Education in Anaesthesia, Critical Care and Pain · October 2003 DOI: 10.1093/bjacepd/mkg151 · Source: OAI CITATIONS...

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/30966949 Anaesthesia for breast surgery Article in Continuing Education in Anaesthesia, Critical Care and Pain · October 2003 DOI: 10.1093/bjacepd/mkg151 · Source: OAI CITATIONS READS 7 4,860 2 authors: Andrew J Westbrook D. Buggy St. Vincents University Hospital Mater Misericordiae University Hospital, University College Dublin 19 PUBLICATIONS 1,223 CITATIONS 268 PUBLICATIONS 11,862 CITATIONS SEE PROFILE SEE PROFILE All content following this page was uploaded by D. Buggy on 03 July 2014. The user has requested enhancement of the downloaded file.  Anaesthesia for breast surgery Andrew J Westbrook FCARCSI Donal J Buggy MD MSc DipMedEld FRCPI FCARCSI FRCA Although cancer is a major indication for breast anastomose across the midline of the anteri- surgery, there are numerous others: for exam- or chest wall and the deep veins accompany Key points ple, benign lump excision, abscess incision and the arteries, draining into the azygous and The prevalence of breast drainage, breast reduction or augmentation, and vertebral veins. This may explain the ten- cancer is increasing. reconstructive procedures after mastectomy. dency of breast cancer to metastasise to the Patients are often very Breast cancer is the most frequent cancer in vertebrae. The breast derives its nerve sup- anxious. women and is responsible for 20% of cancer ply from the intercostal nerves (anterior Extensive breast surgery is amenable to regional anaes- deaths; its incidence in women > 50 years is 1 rami of T1–T5). Downloaded from http://ceaccp.oxfordjournals.org/ by guest on April 16, 2012 thesia and analgesia, especially in 400 per year. Its prevalence has increased continuous paravertebral dramatically due to improved survival and Pathology blockade. introduction of screening programmes. Postoperative nausea and Breast disease may be benign or malignant. vomiting is a frequent Risk factors for breast cancer include age, Benign conditions include infective or problem. environment, earlier menarche and later inflammatory conditions. Breast cancer may Chronic pain after breast menopause, age at first pregnancy, family his- be classified as non-invasive and invasive surgery is common and may tory, previous benign breast disease, radia- require early multidisciplinary (Table 2) or according to prognostic factors. tion, life-style (diet, weight, alcohol intake), management. In the latter, a score may be allocated oral contraceptives and hormone replacement depending on the extent of tumour size, therapy. Some 5–8% of breast cancers are axillary node involvement and degree of genetic, the associated genes being BRCA-1, histological differentiation. BRCA-2 and P53. Anatomy Anaesthesia for breast surgery Pre-operative assessment The adult female breast is an exocrine gland. It consists of two components: (i) epithelial Pre-operative assessment is essential in order elements (acini and ducts) responsible for to establish rapport with the patient, identify milk formation and transport; and (ii) sup- co-existing disease, instigate appropriate opti- porting tissue (muscle, fascia and fat). The misation therapy and plan peri-operative man- epithelial elements are grouped in 20 or more agement. It also allows discussion of the lobes. Each lobe drains into a mammary duct patient’s concerns and proposed management. which ends at the nipple. The arterial blood Specifically, in the context of breast surgery, Andrew J Westbrook FCARCSI Specialist Registrar, Department of supply, venous drainage and lymph drainage Anaesthesia and National Breast Table 2 Classification of breast cancer based on are listed in Table 1. The superficial veins invasiveness Screening Programme, Mater Misericordiae Hospital, Dublin 7, Ireland Non-invasive Invasive Table 1 Blood supply, venous and lymphatic drainage Donal J Buggy MD MSc DipMedEld Intraductal carcinoma Invasive ductal carcinoma of the breast FRCPI FCARCSI FRCA Intraductal carcinoma (with or without Paget’s disease) Arterial Venous Lymphatic with Paget’s disease Invasive lobular carcinoma Consultant Anaesthetist, Department of supply drainage drainage Lobular carcinoma Medullary carcinoma Anaesthesia and National Breast in situ Colloid carcinoma Screening Programme, Mater Axillary Superficial and Axillary nodes Tubular carcinoma Misericordiae Hospital, Dublin 7, Ireland Intercostals (T1–5) deep (drain into Internal mammary Adenoid carcinoma Tel: +353 1 830 1122/803 2281 Internal mammary azygous and nodes Apocrine carcinoma Fax: +353 1 830 0080 vertebral veins) Invasive papillary carcinoma E-mail: [email protected] (for correspondence) DOI 10.1093/bjacepd/mkg151 British Journal of Anaesthesia | CEPD Reviews | Volume 8 Number 5 2003 © The Board of Management and Trustees of the British Journal of Anaesthesia 2003 151 Anaesthesia for breast surgery patient anxiety and the possibility of immune compromise For procedures less than 1 h in duration, a LMA provides ade- from recent chemotherapy are common issues. quate airway control in most cases. A spontaneously breathing There are no pre-operative tests specific for breast surgery patient will usually give adequate operating conditions for the other than those which may be indicated by intercurrent disease. surgeon. Mechanical ventilation is indicated in obese patients After chemotherapy, a routine full blood count is reasonable to (body mass index > 30), risk of aspiration, reconstructive proce- assess haemoglobin, white cell count and platelet count, which dures and prolonged procedures. In cases where regional anaes- may be altered by bone marrow suppression. Cases where sig- thetic techniques are contra-indicated or refused (see below), a nificant blood loss is expected (e.g. reconstructive breast proce- balanced general anaesthesia technique, including systemic opi- dures, mastectomy where breasts are large or after radiotherapy) oids and NSAIDs can be employed. Intravenous opioids can be should routinely have a full blood count and blood typing for continued into the postoperative period, often using patient-con- possible cross-match. trolled analgesia. Anxiety is a particular feature of patients awaiting surgery for breast cancer and gaining the patient’s confidence at pre-opera- Downloaded from http://ceaccp.oxfordjournals.org/ by guest on April 16, 2012 Regional anaesthesia tive assessment is paramount. Anxiolysis may be supplemented When considering regional anaesthesia for breast surgery, a with temazepam 10–20 mg, diazepam 5–10 mg or lorazepam 2–3 mg. Benzodiazepines have been shown to reduce heart rate, risk-benefit assessment is undertaken based on the individual systolic blood pressure and anxiety in the pre-operative period. patient’s needs. A regional technique continued into the post- Their use also assists in laryngeal mask airway insertion. While operative period potentially offers attenuation of the surgical the administration of anxiolytics to patients where an overnight stress response, superior postoperative analgesia, reduction in stay is envisaged is common practice, their use in day surgery PONV and earlier mobilisation in patients undergoing exten- remains controversial. sive surgery. However, the risks associated with regional anaesthetic techniques in fit patients undergoing minor surgery probably outweigh their benefits. Cases of intermedi- Induction and maintenance of anaesthesia ate complexity such as mastectomy and axillary clearance Standard monitoring as recommended by the Association of usually benefit from regional anaesthesia in terms of the qual- Anaesthetists of Great Britain and Ireland is appropriate; i.e. ity of early recovery but its influence on longer-term outcome pulse oximetry, non-invasive blood pressure measurement, heart is unknown. rate, ECG, inspired oxygen concentration and end-tidal carbon Breast surgery is amenable to 4 types of regional anaesthe- dioxide partial pressure. For longer procedures (e.g. radical mas- sia/analgesia techniques – paravertebral block, thoracic tectomy with axillary clearance, prolonged cosmetic and all epidural, multiple intercostal blocks and intrapleural block. reconstructive procedures), temperature monitoring with a fluid The advantages and disadvantages are summarised in Table 3. warmer and forced air warming system should be considered. Pioneered by Hugo Sellheim of Leipzig in 1905, paraver- Additional invasive haemodynamic monitoring may be indicat- tebral nerve block (PVB) has enjoyed a resurgence in the last ed by the patient’s pre-operative cardiorespiratory status. Large- decade and produces analgesia through injection of local bore intravenous access is established. A urinary catheter may anaesthetic along the ipsilateral vertebral column. It may be suffice for measurement of volume status in low risk patients, Table 3 Advantages and disadvantages of regional anaesthetic techniques otherwise central venous monitoring may be indicated. Advantages Disadvantages Both IV and inhalational induction is appropriate. Propofol Attenuate surgical stress response Significant failure rate with has many advantages. A rapid onset of anaesthesia, rapid Superior analgesia continuous techniques (20% epidural, emergence and blunting of airway reflexes make it ideal Less or no opioid consumption 10% PVB) Less PONV Local anaesthetic toxicity (very rare) where laryngeal mask airway (LMA) insertion is planned. Its Early mobilisation Pneumothorax (1% PVB, 2% proposed anti-emetic properties are also potentially helpful. Avoids immune function inhibition intrapleural, 2% intercostal) Bleeding risk (especially epidural Maintenance of anaesthesia may be provided by total intra- haematoma) venous anaesthesia (TIVA) with propofol or a volatile agent Dural puncture Contra-indicated in local infection in an oxygen/nitrous oxide mixture. For most women, Hypotension Urinary retention sevoflurane or isoflurane are suitable agents. 152 British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 5 2003  Anaesthesia for breast surgery used in unilateral trunk surgery, including breast procedures. of fluid at the diaphragm may lead to impairment of respiratory When used for unilateral breast surgery, it provides high qual- muscle function, secretion retention and lower respiratory tract ity pain relief and an opioid-sparing effect. A functional PVB infection. Large doses are required to provide breast analgesia. may provide adequate conditions for surgery on its own but is The risk of pleural or pulmonary damage with intrapleural block more usually combined with general anaesthesia. Compared is greater than for the paravertebral technique. Retrospective with patients who undergo only general anaesthesia, patients analysis shows a 2% incidence of pneumothorax with intrapleur- who receive a PVB alone or in combination with general al block compared with 0.5% with PVB. anaesthesia have a shorter recovery time, less pain and PONV, Multiple intercostal blocks may be effective. However, require fewer analgesics and mobilise earlier. there is a need for multiple injections and further difficulties PVB has an extremely low potential for neurological dam- include incomplete block and a greater risk of pneumothorax age. The presence of a coagulation disorder is a relative, but not or pulmonary damage. an absolute, contra-indication; the neurological consequences of a paravertebral haematoma are small when compared with that Other considerations Downloaded from http://ceaccp.oxfordjournals.org/ by guest on April 16, 2012 of an epidural haematoma. Local sepsis, or the presence of a par- Cosmetic result is often a cornerstone of breast surgical prac- avertebral metastasis, are relative contra-indications. The tice. With this in mind, surgical incisions tend to be small, haemodynamic consequences of a correctly placed bolus of making haemostasis difficult. In addition, blood loss can be large local anaesthetic in a normally hydrated patient are less than that and occur over a short period of time in the more extensive pro- associated with thoracic epidural anaesthesia. Local anaesthetic cedures. Occasionally, breast surgeons also request ptosis of the agents (e.g. bupivacaine or levo-bupivacaine 0.25% 10–15 ml breast, achieved by the reverse Trendelenberg position. bolus, followed by a continuous infusion of 8–15 ml h–1) are Therefore, vigilant haemodynamic monitoring and aggressive often used alone because no opioid receptors exist in the par- correction of any abnormalities are required. Moreover, venous avertebral space. Uptake of local anaesthetic is rapid, resulting pressure in the lower limbs may be increased, increasing the risk in high peak plasma concentrations. This may justify the use of of thrombo-embolic events. This risk can be minimised by the the new, less toxic agents. PVB may be performed as multiple use of compression stockings, venous flow pumps and heparin single-injection techniques or repeated bolus dosing followed by prophylaxis. With regard to procedures involving rotational a continuous infusion via a catheter in the paravertebral space. flaps, maintenance of intravascular volume and filling pressures The technique of PVB has been described elsewhere. In brief, are the best way to maintain cardiac index and organ perfusion. the 2nd or 3rd thoracic spinous process is identified. A point Indirectly acting sympathomimetic agents such as ephedrine, 3 cm lateral to the upper border of the spinous process on the whilst useful in the short-term, can be detrimental by causing side of surgery is marked. This corresponds to the transverse vasoconstriction of the flap circulation, threatening flap viabili- process of the vertebra below. After encountering this bony point ty. Maintenance of normothermia reduces surgical bleeding and at 2–5 cm, the needle is ‘walked’ off the transverse process in a wound infection. caudal direction and advanced anteriorly using a loss of resis- tance technique until the paravertebral space is encountered Postoperative management (usually within 1–1.5 cm deep to the edge of the transverse process). A catheter may be inserted so that 3–5 cm of the distal All patients are monitored in the recovery room with empha- end of the catheter lies within the thoracic paravertebral space. sis on haemodynamic stability and bleeding. Oxygen or intra- Thoracic epidural anaesthesia also has the potential to pro- venous fluid therapy is prescribed where appropriate. High vide good conditions for surgery. However, it may be a techni- dependency care may be need after extensive procedures or if cally difficult procedure and may be associated with hypoten- the patient has significant co-morbidity. Early postoperative sion, urinary retention and post dural puncture headache. mobilisation and physiotherapy is important in the prevention Neurological damage from an epidural haematoma is an of thrombo-embolic disease, shoulder pain/dysfunction and extremely rare, but potentially devastating, complication. upper limb oedema. Intrapleural analgesia requires injection of local anaesthetic Balanced postoperative analgesia may include regional into the pleural space. Most studies have shown improved anal- anaesthetic techniques, systemic opioids and NSAIDs. gesia and reduced opioid requirements. However, accumulation Continuous paravertebral or epidural catheters should be British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 5 2003 153 Anaesthesia for breast surgery clearly labelled and appropriate monitoring performed, surgery are cancer, extensive surgery (especially axillary including documentation of dermatomal sensory level. clearance and breast reconstruction), intensity of postopera- Ideally, these patients should come under the care of the Acute tive pain, postoperative surgical complications (e.g. infection, Pain Service. bleeding) and postoperative radiotherapy or chemotherapy. Many studies have shown that breast surgery is associated Strategies to reduce chronic pain after breast surgery with a high incidence (30–40%) of postoperative nausea and include optimising postoperative analgesia. Early recognition vomiting (PONV). Its aetiology is multifactorial and includes and management of a chronic pain syndrome will improve age, obesity, history of motion sickness or previous PONV, outcome. A multidisciplinary approach is often required. surgical procedure, anaesthetic technique, and amount of postoperative pain. Care should be taken to eliminate known Key references causative factors and many utilise prophylactic anti-emetic Coveney E. Weltz CR. Greengrass R et al. Use of paravertebral block therapy for breast surgery. anesthesia in the surgical management of breast cancer: experience in 156 cases. Ann Surg 1998; 227: 496–501 Downloaded from http://ceaccp.oxfordjournals.org/ by guest on April 16, 2012 Dixon M. (ed) ABC of Breast Diseases, 2nd edn. London: BMJ Publishing Chronic pain after breast surgery Group, 2000 Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95: There is increasing recognition that chronic pain is a signifi- 771–80 cant problem after breast surgery. Typically, it occurs in the Kehlet H, Holte K. Effect of post-operative analgesia on surgical out- affected anterior chest wall, ipsilateral axilla or upper arm. Its come. Br J Anaesth 2001; 87: 62–72 incidence one year after surgery has been reported as 25–30% Wallace MS,Wallace AM, Lee J, Dobke MK. Pain after breast surgery. Pain and includes nociceptive and/or neuropathic pain symptoms. 1996; 66: 195–205 Risk factors for the development of chronic pain after breast See multiple choice questions 110–112. 154 British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 5 2003 View publication stats