What is the anaesthetic management for excision of breast lesion and lymph node clearance?

From the Guidelines

The anesthetic management for excision of breast lesion and lymph node clearance should prioritize regional techniques, such as paravertebral block, to improve postoperative analgesia and reduce opioid requirements. The choice of anesthesia technique is crucial in minimizing morbidity, mortality, and improving quality of life for patients undergoing this procedure. According to the guideline for pain management after oncological breast surgery by Jacobs et al. 1, local anaesthetic wound infiltration resulted in a reduction in pain scores, but the effect was limited to the sixth hour. In contrast, paravertebral block was found to provide improved analgesia with lower pain scores and reduced rescue analgesic requirement compared to local anaesthetic wound infiltration.

Key considerations for anesthetic management include:

• General anesthesia with standard monitoring (ECG, pulse oximetry, non-invasive blood pressure, temperature) and induction with propofol, fentanyl, and a muscle relaxant
• Regional anesthesia techniques like thoracic paravertebral block (15-20 ml of 0.25% bupivacaine) or pectoral nerve blocks (PECS I and II with 10 ml of 0.25% bupivacaine each) for postoperative analgesia
• Multimodal analgesia with acetaminophen, NSAIDs, and opioids as needed
• Antiemetics such as ondansetron and dexamethasone to prevent PONV
• Careful positioning and maintenance of normothermia to reduce the risk of complications

The use of paravertebral block, as recommended by Jacobs et al. 1, can provide effective postoperative analgesia and reduce opioid requirements, ultimately improving patient outcomes and quality of life. By prioritizing regional techniques and multimodal analgesia, anesthesiologists can minimize morbidity and mortality associated with excision of breast lesion and lymph node clearance.

From the Research

Anaesthetic Management for Excision of Breast Lesion and Lymph Node Clearance

The anaesthetic management for excision of breast lesion and lymph node clearance can be achieved through various techniques, including:

• General anesthesia
• Regional anesthesia, such as thoracic epidural anesthesia (TEA) and paravertebral block (PVB) 2
• Peripheral nerve blocks, such as pectoralis nerve (Pecs) II block and internal intercostal plane block 3, 4
• Combined ultrasound-guided Pecs II block and general anesthesia 3

Benefits of Regional Anesthesia

Regional anesthesia has been shown to provide several benefits, including:

• Reduced postoperative pain and opioid consumption 2, 3, 5
• Decreased postoperative nausea and vomiting 5
• Shorter hospital stays 5
• Potential attenuation of perioperative immunosuppression and minimization of metastases in breast cancer patients 5

Specific Techniques

Some specific techniques that have been used for anaesthetic management of breast surgery include:

• Retrolaminar paravertebral block (RLB), which has been shown to delay the time to initial administration of analgesics, but may not reduce the analgesic requirement within the 12-hour postoperative period 2
• Pecs II block, which has been shown to be effective in reducing pain both intra- and postoperatively in patients undergoing modified radical mastectomy 3
• Internal intercostal plane block, which has been used in combination with Pecs II block for regional anesthesia in breast surgery 4

Comparison of Regional and General Anesthesia

A randomized controlled trial compared the use of regional anesthesia-analgesia (paravertebral blocks and propofol) with general anesthesia (sevoflurane) and opioid analgesia, and found no difference in breast cancer recurrence or persistent incisional pain between the two groups 6