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).
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: donal.buggy@nbsp.ie
(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
from recent chemotherapy are common issues.
There are no pre-operative tests specific for breast surgery
other than those which may be indicated by intercurrent disease.
After chemotherapy, a routine full blood count is reasonable to
assess haemoglobin, white cell count and platelet count, which
may be altered by bone marrow suppression. Cases where sig-
nificant blood loss is expected (e.g. reconstructive breast proce-
dures, mastectomy where breasts are large or after radiotherapy)
should routinely have a full blood count and blood typing for
possible cross-match.
Anxiety is a particular feature of patients awaiting surgery for
breast cancer and gaining the patient’s confidence at pre-opera-
tive assessment is paramount. Anxiolysis may be supplemented
with temazepam 10–20 mg, diazepam 5–10 mg or lorazepam
2–3 mg. Benzodiazepines have been shown to reduce heart rate,
systolic blood pressure and anxiety in the pre-operative period.
Their use also assists in laryngeal mask airway insertion. While
the administration of anxiolytics to patients where an overnight
stay is envisaged is common practice, their use in day surgery
remains controversial.
Induction and maintenance of anaesthesia
Standard monitoring as recommended by the Association of
Anaesthetists of Great Britain and Ireland is appropriate; i.e.
pulse oximetry, non-invasive blood pressure measurement, heart
rate, ECG, inspired oxygen concentration and end-tidal carbon
dioxide partial pressure. For longer procedures (e.g. radical mas-
tectomy with axillary clearance, prolonged cosmetic and all
reconstructive procedures), temperature monitoring with a fluid
warmer and forced air warming system should be considered.
Additional invasive haemodynamic monitoring may be indicat-
ed by the patient’s pre-operative cardiorespiratory status. Large-
bore intravenous access is established. A urinary catheter may
suffice for measurement of volume status in low risk patients,
otherwise central venous monitoring may be indicated.
Both IV and inhalational induction is appropriate. Propofol
has many advantages. A rapid onset of anaesthesia, rapid
emergence and blunting of airway reflexes make it ideal
where laryngeal mask airway (LMA) insertion is planned. Its
proposed anti-emetic properties are also potentially helpful.
Maintenance of anaesthesia may be provided by total intra-
venous anaesthesia (TIVA) with propofol or a volatile agent
in an oxygen/nitrous oxide mixture. For most women,
sevoflurane or isoflurane are suitable agents.
152 British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 5 2003
For procedures less than 1 h in duration, a LMA provides ade-
quate airway control in most cases. A spontaneously breathing
patient will usually give adequate operating conditions for the
surgeon. Mechanical ventilation is indicated in obese patients
(body mass index > 30), risk of aspiration, reconstructive proce-
dures and prolonged procedures. In cases where regional anaes-
thetic techniques are contra-indicated or refused (see below), a
balanced general anaesthesia technique, including systemic opi-
oids and NSAIDs can be employed. Intravenous opioids can be
continued into the postoperative period, often using patient-con-
trolled analgesia.
Regional anaesthesia
When considering regional anaesthesia for breast surgery, a
risk-benefit assessment is undertaken based on the individual
patient’s needs. A regional technique continued into the post-
operative period potentially offers attenuation of the surgical
stress response, superior postoperative analgesia, reduction in
PONV and earlier mobilisation in patients undergoing exten-
sive surgery. However, the risks associated with regional
anaesthetic techniques in fit patients undergoing minor
surgery probably outweigh their benefits. Cases of intermedi-
ate complexity such as mastectomy and axillary clearance
usually benefit from regional anaesthesia in terms of the qual-
ity of early recovery but its influence on longer-term outcome
is unknown.
Breast surgery is amenable to 4 types of regional anaesthe-
sia/analgesia techniques – paravertebral block, thoracic
epidural, multiple intercostal blocks and intrapleural block.
The advantages and disadvantages are summarised in Table 3.
Pioneered by Hugo Sellheim of Leipzig in 1905, paraver-
tebral nerve block (PVB) has enjoyed a resurgence in the last
decade and produces analgesia through injection of local
anaesthetic along the ipsilateral vertebral column. It may be
Table 3 Advantages and disadvantages of regional anaesthetic techniques
Advantages Disadvantages
Attenuate surgical stress response Significant failure rate with
Superior analgesia continuous techniques (20% epidural,
Less or no opioid consumption 10% PVB)
Less PONV Local anaesthetic toxicity (very rare)
Early mobilisation Pneumothorax (1% PVB, 2%
Avoids immune function inhibition intrapleural, 2% intercostal)
Bleeding risk (especially epidural
haematoma)
Dural puncture
Contra-indicated in local infection
Hypotension
Urinary retention

used in unilateral trunk surgery, including breast procedures.
When used for unilateral breast surgery, it provides high qual-
ity pain relief and an opioid-sparing effect. A functional PVB
may provide adequate conditions for surgery on its own but is
more usually combined with general anaesthesia. Compared
with patients who undergo only general anaesthesia, patients
who receive a PVB alone or in combination with general
anaesthesia have a shorter recovery time, less pain and PONV,
require fewer analgesics and mobilise earlier.
PVB has an extremely low potential for neurological dam-
age. The presence of a coagulation disorder is a relative, but not
an absolute, contra-indication; the neurological consequences of
a paravertebral haematoma are small when compared with that
of an epidural haematoma. Local sepsis, or the presence of a par-
avertebral metastasis, are relative contra-indications. The
haemodynamic consequences of a correctly placed bolus of
local anaesthetic in a normally hydrated patient are less than that
associated with thoracic epidural anaesthesia. Local anaesthetic
agents (e.g. bupivacaine or levo-bupivacaine 0.25% 10–15 ml
bolus, followed by a continuous infusion of 8–15 ml h–1) are
often used alone because no opioid receptors exist in the par-
avertebral space. Uptake of local anaesthetic is rapid, resulting
in high peak plasma concentrations. This may justify the use of
the new, less toxic agents. PVB may be performed as multiple
single-injection techniques or repeated bolus dosing followed by
a continuous infusion via a catheter in the paravertebral space.
The technique of PVB has been described elsewhere. In brief,
the 2nd or 3rd thoracic spinous process is identified. A point
3 cm lateral to the upper border of the spinous process on the
side of surgery is marked. This corresponds to the transverse
process of the vertebra below. After encountering this bony point
at 2–5 cm, the needle is ‘walked’ off the transverse process in a
caudal direction and advanced anteriorly using a loss of resis-
tance technique until the paravertebral space is encountered
(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
end of the catheter lies within the thoracic paravertebral space.
Thoracic epidural anaesthesia also has the potential to pro-
vide good conditions for surgery. However, it may be a techni-
cally difficult procedure and may be associated with hypoten-
sion, urinary retention and post dural puncture headache.
Neurological damage from an epidural haematoma is an
extremely rare, but potentially devastating, complication.
Intrapleural analgesia requires injection of local anaesthetic
into the pleural space. Most studies have shown improved anal-
gesia and reduced opioid requirements. However, accumulation
British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 5 2003
Anaesthesia for breast surgery
of fluid at the diaphragm may lead to impairment of respiratory
muscle function, secretion retention and lower respiratory tract
infection. Large doses are required to provide breast analgesia.
The risk of pleural or pulmonary damage with intrapleural block
is greater than for the paravertebral technique. Retrospective
analysis shows a 2% incidence of pneumothorax with intrapleur-
al block compared with 0.5% with PVB.
Multiple intercostal blocks may be effective. However,
there is a need for multiple injections and further difficulties
include incomplete block and a greater risk of pneumothorax
or pulmonary damage.
Other considerations
Cosmetic result is often a cornerstone of breast surgical prac-
tice. With this in mind, surgical incisions tend to be small,
making haemostasis difficult. In addition, blood loss can be large
and occur over a short period of time in the more extensive pro-
cedures. Occasionally, breast surgeons also request ptosis of the
breast, achieved by the reverse Trendelenberg position.
Therefore, vigilant haemodynamic monitoring and aggressive
correction of any abnormalities are required. Moreover, venous
pressure in the lower limbs may be increased, increasing the risk
of thrombo-embolic events. This risk can be minimised by the
use of compression stockings, venous flow pumps and heparin
prophylaxis. With regard to procedures involving rotational
flaps, maintenance of intravascular volume and filling pressures
are the best way to maintain cardiac index and organ perfusion.
Indirectly acting sympathomimetic agents such as ephedrine,
whilst useful in the short-term, can be detrimental by causing
vasoconstriction of the flap circulation, threatening flap viabili-
ty. Maintenance of normothermia reduces surgical bleeding and
wound infection.
Postoperative management
All patients are monitored in the recovery room with empha-
sis on haemodynamic stability and bleeding. Oxygen or intra-
venous fluid therapy is prescribed where appropriate. High
dependency care may be need after extensive procedures or if
the patient has significant co-morbidity. Early postoperative
mobilisation and physiotherapy is important in the prevention
of thrombo-embolic disease, shoulder pain/dysfunction and
upper limb oedema.
Balanced postoperative analgesia may include regional
anaesthetic techniques, systemic opioids and NSAIDs.
Continuous paravertebral or epidural catheters should be
153
Anaesthesia for breast surgery
clearly labelled and appropriate monitoring performed,
including documentation of dermatomal sensory level.
Ideally, these patients should come under the care of the Acute
Pain Service.
Many studies have shown that breast surgery is associated
with a high incidence (30–40%) of postoperative nausea and
vomiting (PONV). Its aetiology is multifactorial and includes
age, obesity, history of motion sickness or previous PONV,
surgical procedure, anaesthetic technique, and amount of
postoperative pain. Care should be taken to eliminate known
causative factors and many utilise prophylactic anti-emetic
therapy for breast surgery.
Chronic pain after breast surgery
There is increasing recognition that chronic pain is a signifi-
cant problem after breast surgery. Typically, it occurs in the
affected anterior chest wall, ipsilateral axilla or upper arm. Its
incidence one year after surgery has been reported as 25–30%
and includes nociceptive and/or neuropathic pain symptoms.
Risk factors for the development of chronic pain after breast
154 British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 5 2003
surgery are cancer, extensive surgery (especially axillary
clearance and breast reconstruction), intensity of postopera-
tive pain, postoperative surgical complications (e.g. infection,
bleeding) and postoperative radiotherapy or chemotherapy.
Strategies to reduce chronic pain after breast surgery
include optimising postoperative analgesia. Early recognition
and management of a chronic pain syndrome will improve
outcome. A multidisciplinary approach is often required.
Key references
Coveney E. Weltz CR. Greengrass R et al. Use of paravertebral block
anesthesia in the surgical management of breast cancer: experience
in 156 cases. Ann Surg 1998; 227: 496–501
Dixon M. (ed) ABC of Breast Diseases, 2nd edn. London: BMJ Publishing
Group, 2000
Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95:
771–80
Kehlet H, Holte K. Effect of post-operative analgesia on surgical out-
come. Br J Anaesth 2001; 87: 62–72
Wallace MS,Wallace AM, Lee J, Dobke MK. Pain after breast surgery. Pain
1996; 66: 195–205
See multiple choice questions 110–112.