What the Anesthesiologist Should Know before the Operative Procedure

Surgery for breast reconstruction after mastectomy is entirely elective in nature. Many women select to have the reconstruction done at the time of the initial surgery. Reconstruction is possible if there is no evidence of metastatic disease and the axillary sentinel node is negative. The reconstruction will be delayed if chemotherapy and/or radiation is indicated.

Reconstruction done prior to radiation treatment has been shown to be associated with an increased risk of healing problems secondary to skin burns, seroma formation, and infection. Radiation may also affect the type of implant that can be used. Immediate reconstruction does result in a much longer surgery and may involve tissue expanders if there is not enough skin to cover the implant. This increased complexity commits the patient to further surgical procedures over time.

There are a variety of possible flap procedures that use the patient’s own skin and muscle to create a breast or a pocket for an implant, including a TRAM flap, latissimus dorsi flap, and a gluteal free flap.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

All breast reconstruction surgery is elective. The only surgery after mastectomy that is urgent in nature is reconstruction that is done for bleeding or infection related to the mastectomy procedure itself.

2. Preoperative evaluation

Routine medical clearance is indicated for reconstruction surgery at the time of the initial mastectomy procedure and must be reevaluated if the surgery is following chemotherapy and/or radiation treatment. Chemotherapy and radiation may have side effects on the patient’s health and implications of surgical risk. Patients should also be questioned about the level of exertion that they can accomplish without significant symptoms of fatigue, dizziness, chest pain, palpitations, or shortness of breath. Any positive findings require further medical workup prior to proceeding with this nonurgent surgery.

Also, any coexisting diseases need to be evaluated and should be stable or evaluated by the patient and surgeon prior to the operation.

Medically unstable conditions warranting further evaluation include myocardial infarction and active ischemia, unstable arrhythmias, stroke, TIAs, and COPD exacerbation. These diagnoses require further assessment, consultation, workup, and stabilization. Delaying surgery is indicated until any or all of these diagnoses are well controlled and unlikely to present any significant increased perioperative morbidity. Therapies such as medication changes, pacemaker and/or AICD insertion, angioplasty, stent placement, valvuloplasty, etc, may greatly improve coexisting illnesses or conditions.

3. What are the implications of coexisting disease on perioperative care?

Perioperative risk reduction strategies

Although it is very unusual for a patient considering breast reconstruction to have significant comorbidities, any patient with an ASA status of 3 or 4 may require perioperative adjustments to monitoring and care. Examples include increased monitoring with an arterial line, central line or intraoperative TEE. More complex patients also require optimal medical therapy up until the time of the procedure, and these patients may require possible post-operative ICU care.

b. Cardiovascular system:

Acute/unstable conditions

Patients need to be evaluated for significant cardiac symptoms; they should be asked about any changes in symptoms of fatigue, exercise tolerance, shortness of breath, palpitations, dizziness, or chest pain. If any clinical suspicion for disease exists, workup may include a 12-lead ECG, Holter monitoring, echocardiogram, troponin levels, a stress test, or, at the very least, a cardiology consultation. Acute ischemia needs to be managed before surgery may proceed. Any patient previously cleared at the time of mastectomy but who has since undergone chemotherapy and/or radiation treatment must be reevaluated.

Chemotherapeutic agents such as Adriamycin and Herceptin have been associated with myocardial depression and ventricular irritability, which can be temporary or permanent. In extreme scenarios, the myocardial dysfunction can be so severe that the patient requires cardiac transplantation. For this reason, pre and post treatment echocardiograms have become routine. Radiation treatment to the chest is associated with accelerated coronary atherosclerotic disease; any symptoms of ischemia should be taken seriously.

Baseline coronary artery disease or cardiac dysfunction—goals of management

Interventions may be as straightforward as adding beta-blockers to control heart rate and increase diastolic filling and perfusion or nitrates for ischemia. In the case of myocardial dysfunction, an anesthetic with minimal myocardial depression may be helpful; afterload reduction often improves forward flow. Preload needs to be maintained in patients with reduced ejection fractions due to myocardial depression. Foley catheters are routinely placed in these surgeries to aid in the fluid management of these patients. Most cardiac medications are continued up until the time of surgery; diuretics are the exception. Antihypertensives may be held especially if a regional anesthetic is considered for postoperative pain management. Aspirin and anticoagulants are held for the perioperative period.

c. Pulmonary:

COPD

Patients with pulmonary disease are at increased risk of postoperative complications such as pneumonia after general anesthesia. A thorough review of smoking history, COPD exacerbations, changes in medications, and symptoms with exertion is indicated. Physical exam and baseline oxygen saturation are important. Rarely are baseline labs or pulmonary function studies indicated or useful. A chest radiograph may be helpful to rule out an infiltrate, an effusion, mild CHF, or pleuritis.

Patients who have had radiation treatment can have significant pulmonary disease such as pneumonitis, restrictive disease, pleuritis, etc. The chest radiograph may show a “ground-glass” appearance even with minimal clinical symptoms. In patients with significant COPD, it is important to maintain the current medication regimen, try to minimize excessive peak airway pressures, and avoid stacking of breaths by maximizing time for exhalation. PEEP may or may not be helpful; the same is true for nebulizer treatments. Regional anesthesia may be helpful postoperatively in patients with pulmonary issues and should be considered.

Reactive airway disease (asthma)

Symptoms of asthma are evaluated by history, physical exam, recent changes in the need for inhalers, recent steroid use, ER visits, and hospitalizations/intubations. Patients should continue all of the medications for reactive airways up to the time of surgery; an inhaler treatment is often helpful just prior to induction of anesthesia and airway manipulation. Opiates may be useful to blunt airway responses, and inhaled anesthetics are superb bronchodilators. Intraoperatively, bronchospasm can be treated by deepening the patient’s anesthetic; low-dose infusions of epinephrine may be considered if the bronchospasm is severe. Again, a regional anesthetic for postoperative pain management may be helpful in this group of patients.

d. Renal-GI:

Routine preoperative labs including chemistries are not necessarily indicated in otherwise healthy individuals. In patients who have undergone chemotherapy, however, electrolytes and BUN and creatinine should be checked preoperatively. Patients recently receiving treatments may be dehydrated with mild to severe electrolyte disturbances—specifically, hypokalemia and hypomagnesemia; some of the chemotherapy agents can be nephrotoxic as well. It is important to correct the electrolyte issues and document renal function preoperatively. If there is pre-existing renal impairment, it is important to re-evaluate the need for potentially nephrotoxic medications such as aminoglycosides and NSAIDs.

The GI issues are part of a routine preoperative assessment for all patients. A review of acid indigestion and reflux symptoms is necessary. A rapid sequence induction may be indicated; treatment of the acid symptoms may be helpful as well.

e. Neurologic:

TIAs and stroke symptoms need further attention prior to proceeding with any elective procedure. Any symptoms elicited in the preoperative assessment require further testing such as CT, MRI, MRA, carotid Doppler, echocardiogram, and a neurology consultation as well. Any significant disease may be a reason to reconsider a surgery such as breast reconstruction.

Acute issues

Any acute issues are a contraindication to elective surgery.

Chronic disease

A history of disease such as seizures, vertigo, or old strokes needs to be well-documented and very stable in nature to proceed with elective surgery. A history of carotid disease should be worked up to determine whether surgery is indicated prior to scheduling other procedures. If surgery is not indicated, there should be an effort to maintain higher perfusion pressures in the perioperative period; an arterial line may be indicated. Regional anesthesia is not contraindicated; however, dosing should be conservative and gradual to avoid abrupt sympathectomy onset. Anticipation of possible hypotension is crucial, and the clinician should have appropriate medications such as phenylephrine ready for treatment.

f. Endocrine:

Patients should be clinically euthyroid and, if diabetic, have reasonably well-controlled glucose levels. Diabetics should be scheduled as the first case in the morning whenever possible, and insulin-dependent diabetics should have glucose checked hourly in the perioperative period.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Cancer surgery as well as any lengthy procedures such as this are a risk factor for the development of deep vein thrombosis and subsequent pulmonary emboli. Patients should receive a dose of an anticoagulant such as subcutaneous heparin if the plastic surgeon is amenable, and the patient should have mechanical compression boots as prophylaxis.

Additionally, patients who have undergone chemotherapy need to be evaluated for anemia, neutropenia, and any evidence of infection. If there is any suspicion of bone marrow suppression, the elective reconstruction should be delayed and hematology consult should be considered. As likely prosthetics may be used in the reconstruction, it is important to have an intact immune system.

Last, anxiety in these patients cannot be underestimated. Patients planning on immediate reconstruction are focused on the mastectomy and the likely intraoperative determination of metastasis to the sentinel node. Breast cancer patients have been living with anxiety since the time of their diagnoses and are often stressed, sleep deprived, and emotionally labile. It is important to be a good listener, sympathetic, and supportive—perhaps more so than in any other preoperative interaction. Benzodiazepines are extremely helpful in the perioperative period. Even in the case of delayed reconstruction, the entire surgical experience is tied to the cancer diagnosis and is often overwhelming.

4. What are the patient's medications and how should they be managed in the perioperative period?

Be sure to include herbals, vitamins, and relevant OTC drugs. Patients on beta-blockers should continue them. Statins should be continued as well; discontinuation may be associated with increased risk of adverse cardiac events. Antihypertensives are usually continued except for ACE inhibitors; these are held only on the morning of surgery. All pulmonary medications should be continued perioperatively. All medications for GI symptoms such as proton pump inhibitors and H2 blockers should not be stopped.

Oral hypoglycemics are held on the day of surgery. Insulin is given in a reduced dose; the patient should take half of the total dose (regular and long acting) as the long acting on the morning of surgery. In the case of Lantus and some of the newer 24-hour drugs, half of that dose is indicated. A blood glucose level should be checked upon arrival to the hospital and hourly throughout the perioperative period. A glucose infusion or more Regular Insulin may be needed.

Antiseizure and anti-Parkinson’s medications should be continued as ordered. Antirheumatoid arthritis medications need to be stopped 1 to 2 weeks prior to surgery depending on the medication. Psychiatric medications are to be continued perioperatively. All herbal medications, supplements, and vitamins should be held the week prior to the surgery.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Patients should be off tamoxifen for the perioperative period. If they are undergoing chemotherapy, it is necessary for the last treatment, especially if it includes Herceptin, to have been at least 3 weeks prior to the surgery date. Any anticoagulants need to be stopped in the week prior to the surgery and should be restarted as soon as it is appropriate postoperatively. If the anticoagulation is for an indwelling stent; cardiology should be consulted preoperatively.

i. What should be recommended with regard to continuation of medications taken chronically?

N/A

j. How to modify care for patients with known allergies

All known allergies should be reviewed with the patient at the preoperative visit and again on the day of surgery.

k. Latex allergy – If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

If the patient has a sensitivity or allergy to latex, the operating room needs to be prepared with latex-free products and drugs.

l. Does the patient have any antibiotic allergies – Common antibiotic allergies and alternative antibiotics

Cephazolin is the perioperative antibiotic of choice, unless the patient has an allergy to this class of drugs. Patients with an allergy to the penicillin family have a 10% to 15% cross-reactivity with cephalosporins. To be safe, clindamycin is usually used in patients with a history of penicillin sensitivity. In patients with a history of MRSA, vancomycin is often the antibiotic of choice.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Ensure an MH cart is available [MH protocol].

Local anesthetics/muscle relaxants

Recall that local anesthetics belong to two chemical classes (amides and esters). If a true allergy is present, it is most likely due to an ester class local anesthetic. Indeed, even in this rare situation the allergy may be from a local anesthetic metabolite such as para-amino-benzoic acid (PABA) or a preservative. If a true allergy is suspected, either a local anesthetic from another chemical class should be used or local anesthetic use should be withheld.

5. What laboratory tests should be obtained and has everything been reviewed?

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Hemoglobin levels: A baseline hemoglobin prior to a lengthy surgery, such as this, may be helpful but is often not necessary unless the patient has received recent chemotherapy or other surgery.

Electrolytes: This is not necessary unless the patient has been undergoing chemotherapy or been on diuretics.

Coagulation panel: If the patient has not been on anticoagulation therapy, these labs are not indicated. A blood bank specimen is valuable to have prior to the start of the procedure.

Imaging: Include stress tests, renal imaging tests, etc. Unless there are symptoms indicating further workup, these tests are not necessary.

Other tests include thyroid tests, etc.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Breast reconstruction encompasses many different possible surgical approaches ranging from:

Using the patient’s own breast tissue.
Placing tissue expanders.
Performing a staged reconstruction.
Adding tissue matrix to supplement the patient’s own muscle and skin to cover the expanders or implants.
Creating a variety of flaps from the lower abdomen, the upper back, or the gluteus region.

For all of these possibilities, general anesthesia is necessary. In addition, the surgery is often lengthy and may require the patient to be in a variety of positions. Some flap surgeries require lengthy revascularization procedures as well.

a. Regional anesthesia

Regional anesthesia has become more desirable as an adjunct to general anesthesia to improve the perioperative experience and help manage postoperative pain issues. Pain is well controlled with a thoracic epidural, bilateral rib blocks, and paravertebral blocks. Regional anesthesia is also useful in reducing the amount of narcotics administered; this in turn reduces the likelihood of PONV. This improved perioperative experience may allow patients to leave the hospital earlier.

Neuraxial

Benefits: The benefits of an epidural, rib blocks, or paravertebral block are the better pain control for the length of the local anesthetic effect postoperatively. They are all safe to perform, and paravertebrals have become routine with the prevalence of ultrasound guidance. The pleura and surrounding anatomy are quite easy to visualize and avoid. Regional anesthesia allows patients to take deep breaths with greater ease, cough to clear secretions, and, in the patient population at risk, may reduce postoperative pulmonary issues. Intraoperatively if used, the single-shot blocks or continuous catheter administration will reduce the amount of general anesthesia needed and may result in a quicker recovery time, shorter recovery room stay, less PONV, and less hypoxia.

Drawbacks: The downside of regional anesthesia is that it is another procedure that is routinely placed preoperatively. Some patients find this additional procedure to be particularly stressful, and they often prefer sedation offered for the procedure. Regional anesthesia does require at least one needle placement, which may result in hematoma, intravascular injection, local anesthetic toxicity, nerve injury, pneumothorax, or patchy or failed block. Regional anesthesia may also increase the need for hemodynamic support/vasoactive agents after placement. Yet another drawback is that regional blocks often do not cover the axilla well, and patients frequently complain of axillary pain from sentinel node dissection or drains placed for the mastectomy/reconstruction.

One issue frequently mentioned is the need for a Foley catheter with the use of regional anesthesia. These patients almost always have a Foley catheter placed intraoperatively, and even in the case of a thoracic epidural, the catheter can be removed shortly after surgery as patients can usually void on their own without issue.

These approaches to regional anesthesia can be done in a preoperative setting prior to moving the patient to the OR. This approach allows for the surgical team and nurses to prepare all of the equipment while the patient is receiving the regional anesthesia. The regional anesthesia placement is done under monitored anesthesia care; sedation is given, the patient is fully monitored. The team must be prepared to provide airway support, induce general anesthesia safely, and resuscitate the patient if the need arises. A provider trained in regional anesthesia issues is important to provide safe care and assist in the block positioning, sedation, and placement.

b. General anesthesia

Benefits

General anesthesia is necessary for this procedure. Endotracheal intubation is indicated because of the length of the case and the possible need to reposition the patient depending on the needs of the reconstruction. Many surgeons will request neuromuscular blockade for the flap dissection and possible revascularization as well as the creation of a pocket for the implant beneath the pectoralis muscles. Special attention should be given to padding the patient’s arms, placement of monitors, and tension on the patient’s shoulder as the surgical team may need to work in the axilla. Careful attention should be given to make certain that there is not pressure placed on the face during the lengthy case as well. A warming blanket can be placed on the lower portion of the patient, but most of the patient’s torso remains exposed for the entire procedure. A Foley catheter should be placed to make fluid management easier and as the procedure can be quite lengthy.

Airway concerns: There are no special airway concerns in these cases.

c. Monitored anesthesia care

Monitored anesthesia care is not an option for these procedures but is necessary for the placement of the regional anesthetic if one is placed preoperatively.

6. What is the author's preferred method of anesthesia technique and why?

My preferred method of anesthesia is the preoperative placement of a thoracic epidural catheter or paravertebral block—the choice depends largely on the patient’s anatomy and the availability of ultrasound guidance for the paravertebral blocks. The epidural catheter allows for redosing, extending the length of time the patient is comfortable before oral or intravenous narcotics are employed.

What prophylactic antibiotics should be administered?

Use current SCIP recommendations: Cephazolin 2 grams q 4 hours intraoperatively is the current recommendation.

What do I need to know about the surgical technique to optimize my anesthetic care?

To provide quality anesthesia care, it is important to know the surgical plan for the reconstruction as each approach has implications for the positioning of the patient, the need for muscle relaxation, concerns around flap vascular integrity, and pain issues for the patient. If the reconstruction is performed using tissue expanders and the patient’s own skin and pectoralis muscle, the patient can remain supine and does not need to be repositioned. However, some surgeons prefer to sit the patient up during the operation to verify symmetry of the breasts prior to extubation.

The deep and superficial epigastric artery flaps and TRAM flaps also require the patient to be in the supine position for the case. Muscle relaxation is helpful for dissection. The regional anesthesia options are often not sufficient to cover the large area of surgical stimulation or pain postoperatively and so are often not done. The latissimus dorsi flaps and the gluteal free flaps require the patient be prone for the initial dissection, and then the patient is turned supine for the reconstruction of the breasts.

What can I do intraoperatively to assist the surgeon and optimize patient care?

If the reconstruction is being done immediately following the mastectomy, there are several issues that are important for the best care of the patient. If a sentinel node biopsy is performed with the mastectomy, there is a chance that the patient will require an axillary lymph node dissection. Depending on the nature of the disease—the receptors, the age of the patient, the size and location of the tumor—axillary dissection may or may not be indicated and may lead to postponing the reconstruction until after further treatment of the disease.

Often tissue expanders can be placed but implants are not considered if the patient will need radiation. All of these surgical possibilities need to be discussed in real time. The anesthetic must be planned with the possibility that the reconstruction will not immediately follow the mastectomy. Also, many breast surgeons do not want the patient to be paralyzed when they dissect the axilla. Succinylcholine or a short-acting relaxant may be used for the intubation, allowing recovery during the mastectomy. Many plastic surgeons will then later ask that the patient be paralyzed for the reconstruction part of the procedure.

What are the most common intraoperative complications and how can they be avoided/treated?

Hypotension is probably the most common intraoperative complication. Blood loss is rarely an issue; the patients are usually slightly dehydrated and then vasodilated under general or combination general/regional anesthesia. This is often easily treated with a vasoactive medication such as ephedrine or phenylephrine. Another intraoperative problem is nerve injury from positioning. Checking and rechecking all possible pressure points cannot be overstated.

a. Neurologic:

Neuropathies may develop from pressure points that are not sufficiently padded during the procedure. Flap vascularization may be problematic with both free flaps and flaps with vascular attachments. Avoiding hypotension and the use of excessive vasoconstrictors such as phenylephrine may be helpful.

b. If the patient is intubated, are there any special criteria for extubation?

N/A

c. Postoperative management

Most patients after an appropriate stay in a recovery room setting can be cared for on a regular surgical floor. The major postoperative issues are pain which can be treated with intravenous narcotics or redosing of an epidural catheter if available and PONV which can be treated with a variety of drugs including ondansetron, haloperidol, dexamthasone, scopalamine, ephedrine, and others. Other postoperative issues include emotional lability, which can be helped with family support, sympathetic recovery team, and benzodiazepines as needed. Bleeding can be picked up readily as drains are left in for days to weeks; this is not a common problem. As with any prosthetic implants, infection is a real concern and results in often several subsequent surgeries for the patient; special attention to details to limit infection are very important.

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