Anesthesia=20 for Breast surgery :- a Review

Ravinder=20 Kumar Batra, Madhur Mehta,=20 Department=20 of Anesthesiology,

All=20 India Institute of Medical Sciences,New Delhi

=20 Over the last 30 years , there has been an advancement and = evolution in=20 breast surgery techniques affecting the anesthetic concerns in a breast = cancer=20 patient undergoing surgery . An anaesthesiologist has a vital role to = play in=20 providing perioperative care to these patients who may undergo varying = surgical=20 procedures like breast biopsy, lymph node biopsy , axillary dissection , = lumpectomy, simple / radical / modified radical mastectomy and breast or = chest=20 wall reconstruction . The anaesthetic concerns differ amongst these = patients,=20 depending on many factors including primarily: type of surgical = procedure and=20 perioperative chemotherapy, radiotherapy and therefore , these patients = must be=20 individualized .

Anesthetic concerns for breast biopsy and sentinel lymph node biopsy =

=20 Breast masses may vary in size and depth , which partially = determines the=20 most suitable anaesthetic technique for the particular procedure in = these=20 otherwise healthy patients . Typically , these excisional biopsies can = be=20 accomplished with monitored anesthesia care (MAC) with or without sedation under local = anaesthesia . The=20 suitability of local versus general anaesthesia (GA) may be decided by=20 preoperative discussion with surgical team ; however , patient=92s = wishes must be=20 considered in anaesthetic plan .

=20 These patients are likely to be very anxious perioperatively = concerning=20 the possibility of breast malignancy , and should therefore be reassured = and=20 premedicated adequately with anxiolytics. An oral dose of benzodiazepine = like=20 0.1 to 02 mg/kg of diazepam during night and in the morning 1 hour = before may be=20 given to relieve anxiety. Day care patients may be given shorter acting = agents=20 like midazolam 1-2 mg with or without fentanyl 25-50 mg=20 intravenously prior to=20 induction, in patient = holding area=20 or operating room as an alternative . Standard fasting guidelines are = adhered to=20 as usual . Patients may be taken up for surgery after obtaining = haemogram and other laboratory tests, as = indicated by other co-morbid = conditions=20 of the patient.

=20 GA or local anaesthesia with or without sedation are both = appropriate=20 techniques depending on patient=92s requirement.. Propofol infusion at = 25- 100=20 mg/kg/min,=20 combined with analgesics such as fentanyl, remifentanil or = sufentanil with anxiolytics like = midazolam,=20 titrated, are the most commonly used regimens during MAC. Bupivacaine = (0.25 to=20 0.5 % ) or lignocaine (1 to 2 % ) remain standard drugs used as local=20 anaesthetics, though newer agents like ropivacaine are also promising .=20 Anaesthesiologist may need to supplement surgical field block with local anaesthetic or = occasionally=20 convert to GA . GA may be chosen as the first choice if the size of the swelling is = large=20 or if the patients = refuses for=20 local anaesthesia . Standard anaesthetic techniques for induction and=20 maintenance may be used for GA . Maintenance of airway with a facemask = or=20 laryngeal mask airway ( LMA ) may be appropriate . Muscle relaxants are = not=20 required and best avoided for this short surgical procedure. =

=20 A balanced salt solution like ringer lactate infused at rate of 3 = =965 ml=20 /kg/hour through an 20 = =9622=20 gauge intravenous canula = is used=20 for perioperative fluid management . Minimum monitoring standards are = adopted=20 for these procedure. Additionally , it is important to maintain verbal = contact=20 with patient during =91conscious sedation=92 in MAC ¹ .

=20 Sentinel lymh node identification =20 may involve use of either isosulfan blue vital dye ( lymphozurin = 1% ) or=20 99^m technetium =96 labeled sulfur colloid ( TSC) . Surgeons = should=20 inform the anaesthesiologist when injecting the dye because of a = transient drop=20 by 2-5 % in pulse oximetry readings ². Also, patient may = retain a=20 bluish hue for few hours and may pass blue coloured urine , stool or = emesis for=20 24-48 hours . Allergic reactions varying from mild pruritis with = discolouration=20 of local skin to life threatening anaphylactic reactions have been known = as a=20 complication to dye ^2-4. An antihistaminic like pheniramine = and an=20 anti-inflammatory agent like hydrocortisone may be used for milder forms = of=20 allergic reaction . However , an allergic reaction with hypotension may = require=20 epinephrine boluses and = or infusion=20 . Radiation exposure associated with TSC technique is considered = negligible .=20 The tracer has very low radioactivity and it is considered safe to = handle=20 specimens, which require no special protection.

Anaesthetic=20 concerns for breast conserving surgery and mastectomy =

=20 Treatment=20 of invasive breast cancer has evolved tremendously during recent years. = Radical=20 Mastectomy , which removes breast , underlying pectoral muscles and the = axillary=20 lymph nodes , has been replaced by modified radical mastectomy or = lumpectomy=20 (partial mastectomy ) with axillary dissection . Modified radical = mastectomy=20 (MRM) entails removal of breast and axillary lymph nodes . Lumpectomy = and=20 axillary dissection are normally = done through separate incisions . Post operative adjuvant = radiation=20 therapy is routinely recommended in breast conserving surgery and is=20 administered following the completion of adjuvant chemotherapy . A = simple/ total=20 mastectomy removes only breast tissue without any axillary dissection . = It is=20 done mainly for extensive duct carcinoma in situ.

=20 Anaesthetic=20 implications are for these procedures vary depending upon the possible metastatic spread = through=20 systemic circulation to various organs , and systemic effects of = chemotherapy=20 and radiotherapy in breast cancer patients . Chemotherapeutic induced ( = eg.=20 Adriamycin or Doxorubicin = > 550=20 mg/m²as = cumulative=20 dose) increases the risk of cardiac dysfunction including arrythmias and = congestive cardiac failure (CCF ) unresponsive to digitalis with = mortality of=20 > 50 % ⁵. An acute form of toxicity characterized by ST = and T wave=20 alterations with reversible reduction in =20 ejection fraction due to impaired impulse conduction may = sometimes be=20 seen within 24 hours of single use, though is brief and rarely a serious = problem=20 . Rarely, an exaggerated manifestation of acute myocardial damage may = present as=20 frank CCF with pericardial effusion . =20 A detailed cardiac evaluation by cardiologist employing ECG, ECHO = or=20 MUGA is must in the patients being treated = with such=20 cardiotoxic drugs. Cineangiography is considered as most promising = technique for=20 early detection of CCF .Risk of CCF is aggravated with concomitant = radiotherapy=20 and administration of cyclophophamide .

=20 Chemotherapeutic=20 agents like Bleomycin, Cyclophosphamide and Melphalan are associated = with=20 progressive pulmonary fibrosis . Bleomycin carries the greatest risk of=20 pulmonary toxicity (5-10 % ) with mortality of 1 % .Bleomycin increases=20 secretion of cytokines ( tumor =20 growth factor B and tumor necrosis factor ) = from=20 macrophages, initiating pulmonary fibrosis . It presents as dry cough , = fine rales=20 and diffuse basilar infiltrates on X-ray and may progress to = irreversible=20 pulmonary fibrosis. Radiological changes may present as interstitial = fibrosis,=20 cavitations, atelectasis , lobar collapse or even consolidation .Carbon = Monoxide=20 diffusion capacity is = reduced at=20 doses above cumulative dose of 250 U, though single dose of > 30 U / = m2=20 is also associated with = pulmonary=20 toxicity ⁵ . Administration of high FiO2=20 during anaesthesia / respiratory therapy may aggravate or precipitate = Bleomycin=20 induced pulmonary toxicity and thus it is advisable to avoid=20 FiO₂ > 30 % = in such=20 patients⁵. The risk is also increased in patients above 70 = years and=20 with pre-existing = pulmonary=20 pathology . Preoperatively, a chest X ray is required to rule out = pleural=20 effusion, rib or vertebral metastatic lesion . A room air ABG may be = required in=20 any patient showing clinically respiratory compromise , particularly = those=20 receiving chest radiotherapy . Pulmonary function tests may be indicated = to find=20 pulmonary reserve, risk assessment and identifying patients in need of = post=20 operative ventilatory care, if CXR or ABG suggest abnormal=20 findings.

=20 Breast cancer patients can present with focal neurological = deficits or=20 altered mental status, following metastasis to CNS. Additionally, = headache and=20 vomiting because of intracranial hypertension may be found. Neurologist = should=20 be consulted in such cases and a thorough but prompt work up with CT = scan / MRI=20 is recommended before taking up for surgery. Anemia is common in such = patients=20 because of chronic disease, malnutrition or secondary to = chemotherapeutic agents=20 induced bone marrow depression . A complete hemogram including = differential and=20 platelet count with peripheral smear examination might help in finding = possible=20 cause of anemia. Renal or hepatic dysfunction may be present because of=20 metastatic involvement or toxicity of chemotherapeutic agents. Bone = metastasis=20 may be suggested from increased alkaline phosphates. Chemotherapeutic = induced=20 immunosuppression increases likelihood of infection peri-operatively in = these=20 patients . As such , strict asepsis should be practiced and adequate = antibiotic=20 prophylaxis should be provided .

=20 Preoperative reassurance , =20 counseling and thorough premedication have a crucial role in = preparation=20 of patient for surgery . General anaesthesia with entotracheal = intubation or LMA=20 remains the standard approach in these patients. Standard techniques for = induction, and maintenance of=20 anaesthesia, monitoring are practiced as with patients for biopsies. = However,=20 regional anaesthesia in = breast=20 surgery is associated with less PONV, decreased postoperative pain = and earlier=20 discharge from the hospital ^6-8..

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=20 Although=20 controversial,=20 the=20 use of muscle relaxants during axillary dissection may be avoided to = permit surgical identification of = nerves by=20 nerve stimulator or if electrocautery is used . Longer acting muscle = relaxants like=20 pancuronium are best avoided for same reason . Longer duration=20 (typically=20 few hours) requires = appropriate eye=20 care ( padding / taping ) and padding pressure points . BP cuff and=20 intravenous=20 line,=20 when both are applied on = the same=20 arm = may pose problem of blood rushing = up=20 intravenous tubing , every time BP cuff is inflated . A simple method to = avoid=20 this complication is to route the infusion set tubing through the BP = cuff=20 ⁹ . Alternatively , BP = cuff may=20 be applied to legs.

Typically , these surgeries are = associated with mild to moderate blood loss . A 16 G or 18 G intravenous = canula=20 is appropriate to infuse = balanced=20 salt solution like Ringer Lactate =20 for perioperative fluid management . Blood transfusion is avoided = usually=20 but may sometimes be needed, especially in anaemic patients , if blood = loss=20 exceeds maximal allowable limits . Prophylactic antiemetics are required = in=20 these patients because of high risk of PONV in breast = surgeries.¹⁰=20 . Metoclopramide 0.2 mg/kg iv, Ondansetron 0.1 mg/kg iv or Granisetron 40 = ug/kg iv =20 30 minutes before end of case are commonly used effective = prophylactic=20 antiemetic regimens in these patients =20 ^11,12 .

=20 Unilateral = multiple level=20 paravertebral block = typically=20 blocking C₇-T₆ =20 levels , provides satisfactory anaesthesia for modified radical=20 mastectomy and lumpectomy with axillary lymph node dissection = ^6,7,13=20 . Bupivacaine 0.5% or ropivacaine 0.5 % with or without 1: 3,00,000 = epinephrine=20 are suitable local anaesthetics (4-5 ml/level ) . Sedation is useful = during=20 block placement and is continued intraoperatively . Patient=92s refusal = ,=20 infection at site , previous history of allergy to LA or anatomic = distortion=20 because of pathology or previous surgery may not allow performance of = block .=20 Paravertebral block may also be complicated because of inadequate block, = Horner=92s syndrome , inadvertent epidural and sometimes pleural = puncture and=20 pneumothorax .

=20 Intercostal block has been used successfully as an alternative to = paravertebral block especially = for=20 minor breast surgeries ¹⁴ . Both paravertebral ¹⁵ = and=20 intercostal block ¹⁶ have been performed successfully as a suitable alternative to GA in patients = with=20 advanced breast malignancy or with comorbidities . Thoracic epidural = combined=20 with Interscalene Brachial Plexus Block provides not only effective = anaesthesia=20 but also better postoperative pain relief , faster anaesthetic recovery = and=20 great patient satisfaction as compared to GA⁸ . Recently = ,=20 cervical epidural has also been used as a cheap alternative to GA , however , is generally avoided = because=20 of risk of associated complications ¹⁷ . =20

=20 Post operative pain may be controlled by systemic analgesics = administered=20 (orally), intramuscular diclofenac /ketorolac or intravenous fentanyl ,=20 pethidine , morphine ketorolac by boluses /infusion /PCA ( patient = controlled=20 analgesia ) . Alternatively , a catheter placed in paravertebral or = thoracic=20 epidural space might be used to provide regional analgesia ( boluses = /infusion=20 or PCA ) . Local anaesthetics in lower concentration ( like 0.0625-0.25% = bupivacaine ) and / or opioids (such as fentanyl 2-10 ug /ml ) infused = at 5-8 ml=20 / hour might be appropriate for pain control .

Anaesthetic=20 concerns in patients for breast and chest wall reconstruction

=20 The=20 goal of breast reconstruction is to create an aesthetic breast whereas = that of=20 chest wall reconstruction is to provide a stable chest wall for = respiration and=20 obtain a clean healed wound. In patients undergoing mastectomy , = reconstruction=20 may be performed immediately after the mastectomy or it may be delayed = and=20 performed at a later date . Postoperative chest radiation may be a = relative but=20 not absolute contraindication to immediate reconstruction .=20

=20 Two approaches are commonly used 1) Prosthetic Reconstruction = with a=20 temporary tissue expander or saline filled implant placed behind the = pectoral=20 muscles and 2) Autologous Myocutaneous flaps ( Latissimus dorsi and = transverse=20 rectus abdominis or TRAM flaps ) for breast reconstruction . . Latissimus = dorsi=20 myocutaneous flap consists of muscle with overlying skin rotated from = back to=20 anterior chest for creation of a breast . Usually a breast implant is = placed=20 between latissimus dorsi and pectoralis major to increase volume of = breast . On=20 the other hand , TRAM flap replaces breast with an ellipse of abdominal = skin and=20 subcutaneous tissue = without need of=20 implant and also giving a cosmetic advantage of =91tummy tucked in=92 = appearance . Tumor resection or removal of=20 osteoradionecrosis of the chest wall ,which often involves full = thickness=20 removal of skin, muscle and underlying rib cage may be required in few = cases .=20 The rib cage may be reconstructed with prosthetic material or bone = grafts=20 followed by covering with = pectoralis major , latissimus dorsi or rectus abdominis myocutaneous = flaps .=20

=20 These patients coming for reconstruction , particularly chest = wall=20 reconstructions are at high risk for anaesthetic and surgical problems = because=20 of the associated co-morbidities .

There=20 is a increased likelihood of cardiorespiratory problems in patients = receiving=20 radiotherapy or chemotherapy, as discussed earlier. Additionally, = patients with=20 prior sternotomy or rib resection may have decreased respiratory reserve = and may=20 require assessment with chest X-ray , ABG or PFT=92s . Patients with = respiratory=20 compromise and deranged PFT, CXR or ABG may be at increased risk of=20 peri-operative respiratory complications and need post operative = ventilatory=20 care. It is important to perform a detailed musculoskeletal examination = and=20 document, if any, peripheral nerve involvement such as long thoracic = nerve=20 presenting as winged scapula .Additionally, these patients being at = increased risk=20 of perioperative nausea & vomiting because of chemotherapy as well = as nature=20 of surgery,and may = require=20 anti-emetic prophylaxis .

=20 Preoperative reassurance and premedication with anxiolytics is crucial for = patient=92s=20 preparation for surgery . = General=20 anaesthesia with endotracheal intubation is the standard technique. = Induction=20 and maintenance are achieved with standard protocols as in patients for = breast=20 malignancies . The position during surgery is usually supine or lateral=20 depending on surgical approach . = Good muscle relaxation is an important requirement in such = patients,=20 which may be guided by neuromuscular monitoring. It may be useful to = monitor=20 temperature, urine output and sometimes CVP ( in patients with cardiac=20 dysfunction ) for these prolonged major surgeries (average duration of = 3-6=20 hours) , which may sometimes involve extensive blood loss , as during = sternal=20 debridement . It is important to secure at least one intravenous broad = gauge (16=20 G or larger ) canula before surgery starts .

=20 There may be = certain=20 concerns related to specific surgical procedure in these patients = .Patient=20 warming measures like warming blanket , warm fluids , warm humidified = gases=20 should be used so as to minimize hypothermia induced peripheral = vasoconstriction=20 , which might impair graft perfusion . Patient needs to be kept well = hydrated ,=20 as guided by hemodynamics , blood loss , urine output & CVP , if = used .=20 Blood loss should be measured frequently and replaced , as and when = indicated .=20 Standard care as regard to patient positioning , eye care, padding = pressure=20 points is provided . An arterial line can be helpful in real time = monitoring of=20 blood pressure as well as a source for arterial blood for repeated = analyses in=20 prolonged major surgeries in which extensive blood loss is anticipated . = A close=20 watch on airway pressures , SpO₂ and BP may help in earlier detection = of=20 pneumothorax . =20

Often=20 the patient needs to be = placed in=20 seated or semi-fowler position for skin closure in flap surgeries . This may sometimes provoke = bucking on=20 endotracheal tube , which can be reduced by boluses of lignocaine or opioids such as = fentanyl=20 . Flexion of OT = table may be=20 required by as much as 45-60⁰ during closure and dressing in = TRAM=20 flap surgery Additionally , it is prudent to discontinue = N₂O before closure in these = patients as it=20 may cause abdominal distension and interfere with abdominal closure = .

=20 Reconstruction surgeries are likely to be very painful ( Visual = Analogue=20 pain score of about 5 ) and require systemic opioids by boluses or = infusion or=20 PCA for pain relief . Metoclopramide 0.2 mg/kg iv , ondansetron 0.1 mg/kg iv = or=20 granisetron 40 ug/kg iv are commonly used effective prophylactic = antiemetic=20 regimens in such patients . Furthermore, these patients may require = close=20 observation for few hours in a Post Anaesthesia Care Unit ( PACU ) or = high=20 dependency unit ( HDU ) before they can be safely shifted to ward .=20

References

1- =20 Sa Rego=20 M M , White P . Monitored Anesthesia Care . In : Ronald D. Miller ed. = Anesthesia=20 ,5^th ed .Philadelphia , Pennsylvania: Churchill=20 Livingstone,2000:1452-1469 .

2- =20 Sandhu=20 S, Farag E ,Argalious M . Anaphylaxis to isosulfan blue dye during &n= bsp; =20 sentinel lymph node biopsy . J Clin. Anesth 2005 Dec ; 17 (8) : = 633-5=20 .

3- =20 Sprung J , Tully M J , Ziser A . = Anaphylactic=20 reactions to isosulfan blue dye during sentinel node lymphadenectomy for = breast=20 cancer . Anesth Analg 2003 Apr ; 96 (4) :1051-3 .

4- Scherer K , Studer W , = Figueiredo V ,=20 Bircher A J . Anaphylaxis to isosulfan blue =20

and = cross=20 reactivity to patent blue V : Case report and review of the = nomenclature =

of = vital blue=20 dyes . Ann Allergy = Asthma=20 Immunol 2006 Mar ; 96 (3) : 497-500.

= 5-=20 Chabner B A , Ryan D P , Paz-Ares L etal . Antineoplastic=20 agents .In : Gilman AG, =20

=20 Hardman J G , Limbird L E eds . The pharmacological basis of = therapeutics=20 . 10^th

=20 Ed. McGraw Hill publications , United States of America . 2001:=20 1389- 1460 = .

6- = Coveney E ,=20 Weltz C R , Greenglass R etal . Use of paravertebral block anaesthesia=20

=20 in the surgical management of breast cancer : experience in 156 = cases=20 . Ann Surg.

=20 1998 Apr ; 227(4): 496-501.

7- = Weltz C R ,=20 Greengrass R A , Lyerly H K . Ambulatory surgical management of=20

=20 breast carcinoma using paravertebral block . Ann Surg . 1995 Jul = ;222 (1)=20 : 19-26 .

8- = Sundarathiti=20 P , Pasutharnchat K , Kongdan Y =20 etal . Thoracic epidural anaesthesia

=20 with 0.2% ropivacaine in combination with ipsilateral brachial = plexus=20 block for

=20 modified radical mastectomy . =20 J Med Assoc Thai . 2005 Apr ; 88 = (4):513-20.

9- Dorsch J A, Dorsch S E . = Automatic=20 noninvasive blood pressure monitors . In

=20 Zinner S ed . Understanding Anesthesia Equipment , 4^th = ed.=20 1999: 905-918 .

10- Layeeque R , Siegel E , Kass R = etal .=20 Prevention of nausea and vomiting following

=20 breast surgery . Am J Surg 2006 Jun ; 191 (6) : 767-72=20 .

11- Fujii Y , Tanaka H, Kawasaki = T. A=20 comparison of granisetron , droperidol , and

=20 metoclopramide in the treatment of established nausea and = vomiting after=20 breast =20

=20 surgery : a double blind, randomized , controlled trial . Clin. = Ther .=20 2003 Apr ; 25

=20 (4) 1142-9 .

12- Sadhasivam S, Saxena = A ,=20 Kathirvel S etal .The safety of prophylactic ondansetron =

=20 in patients undergoing modified radical mastectomy. Anesth Analg = 1999 Dec=20 ;

=20 89 (6) : 1340 =965 .

13- Terheggen M A , = Borel Rinkes I=20 H , Lonescu T I et al . Paravertebral blockade for =

=20 minor breast surgery . Anesth Analg 2002 Feb ; 94 (2) : 355-9=20 .

14- Atanassoff P G , = Alon E ,=20 Pasch T etal . Intercostal nerve block for minor breast =

=20 surgery . Reg Anesth 1991 Jan-Feb ; 16 (1) :23-7 = .

15- Najarian M M , = Johnson J M ,=20 Landercasper J etal . Paravertebral block : an

=20 alternative to general anaesthesia in breast cancer surgery . Am = Surg=20 2003 Mar ; 69

=20 (3) : 213-8 .

16- Kolawole I K = ,Adesina M D ,=20 Olaoye I O . Intercostal nerves block for mastectomy =

=20 in two patients with advanced breast malignancy . J Natl Med = Assoc . 2006=20 Mar ;

=20 98 (3) :450-3 .

17- Singh A P , Tewari M = , Singh D=20 K etal . Cervical epidural anaesthesia : a safe

=20 alternative = to general=20 anaesthesia for patients undergoing cancer breast surgery .=20

=20 World J Surg . 2006 Aug 16 ; [ Epub = ahead of=20 print ]