Ricky G.

Jaleco
Level 2 Resident

Western Visayas Medical Center

Department of Anesthesiology

CASE BASED DISCUSSION #3

I. General Data
Patient’s Name: A.F.
Age: 59 y.o.
Sex: F
Civil Status: Married
Birthday: 04/26/1964
Nationality: Filipino
Religion: Jehovah’s Witnesses
Address: Zone 3, Baldoza, La Paz, Iloilo City, Iloilo

II. Chief Complaint

Breast mass left

III. History of Present Illness

4 years PTA, patient noted a 1x1cm mass at the left breast. No other associated signs &
symptoms. No medications taken & no consult was done.

On the interim, there was note of gradual increase of the breast mass.

4 months PTA, patient sought consult at our OPD and work-up was done.

2 weeks PTA, results revealed Invasive Carcinoma with lobular features and was advised for
admission.

IV. Past Medical History

No other known comorbids
No known allergies to drugs, foods, and other environmental agents

V. Personal, Social and Environmental History

Patient is a non-smoker and a non-alcoholic beverage drinker

VI. Physical Examination

Patient is GCS 15, not in cardiopulmonary distress, with baseline vital signs of Vital Signs: BP
130/70, HR 73, RR 20, SpO2 99%. She weighs around 50 kilograms, stands 5’2”, with a BMI of
20.3 kg/m2 and is classified as normal.
 Airway Assessment: Mallampati Class 1, 2 fingerbreadth mouth opening, hyomental distance
>6 cm, thyromental distance >6.5cm, no neck masses, no neck rigidity, no limitations to
cervical motion

Anicteric sclerae, pinkish conjunctiva, (+) 4 x 3 cm left breast mass, symmetrical chest
expansion, clear breath sounds, adynamic precordium normal cardiac rate with regular
rhythm, no note of murmurs, soft abdomen, full peripheral pulses. No sensorimotor deficits
noted.

VII. Admitting Diagnosis

Invasive Mammary Carcinoma Stage 2A (cT2N0M0) s/p Core Needle Biopsy Left (July 2023)

VIII. Laboratory Results

CBC 12.9/0.38/318 WBC 6.2
Na 146.1/K 3.95/Crea 60.10
FBS 5.19
CXR - AA, thoracic hypertrophic degenerative changes
ECG - NSSTWC

IX. Anesthesia Pre-operative Assessment

The patient was classified as ASA 2 for malignancy (breast carcinoma), and with a Mallampati
classification of 1. She was stratified by the Department of Internal Medicine as Intermediate
Risk to develop perioperative complications

The patient was placed on NPO status 8 hours prior the procedure, and was premedicated
with 1) Omeprazole 40 mg IV 1 hour PTOR, and 2) Metoclopramide 10 mg slow IV 1 hour PTOR.

X. Proposed Procedure
Sentinel Lymph Node Biopsy, Mastectomy,
Axillary Lymph Node Dissection, Left

XI. Anesthetic Technique

General Endotracheal Anesthesia

XII. Intra-operative Course

The patient was received at the Operating Room, conscious, coherent, oriented and not in
cardiopulmonary distress. She was then transferred to the operating table and basic monitors
were attached to the patient. Oxygen supplementation was given at 3 liters per minute via
nasal cannula. Baseline vital signs were BP 130/70, HR 73, RR 19, SpO2 100%. The patency of
IV lines were also checked and maintained.
 Anxiolysis was done by giving the patient a dose of Midazolam 1mg IV. Paracetamol 1g IV was
also started while setting up the patient. Preoxygenation was done (8 deep breaths in 60
seconds), induction meds were given for slow sequence induction with: Fentanyl 75 mcg slow
IV, Propofol 100 mg IV, and Atracurium 25 mg IV, direct laryngoscopy was done using Mach
blade 4, Cormack-Lehane grade 1, Endotracheal Tube size 7.5 was inserted at level 20 cm,
attached to a semi-closed circuit system with CO2 absorber. Auscultation was then done, to
check for equal breath sounds. The patient was maintained on Sevoflurane and titrated
accordingly.

Positioning of the patient was then done with the left arm abducted to the side, and the left
elbow flexed. Upon cutting, the patient was stable with vital signs of BP 100/60, HR 60, SpO2
100%.

Around thirty minutes from cutting time, a loading dose of Tramadol 25 mg slow IV was given,
and a Tramadol IV infusion as side drip was started, composed of Tramadol 100 mg + 98cc
normal saline to run for 8 hours at a rate of 12 gtts/min via soluset. Negative skin test on
Ketorolac was also noted, and 30 mg IV was given.

Overall, the intraoperative course was unremarkable. Local infiltration was given upon closing;
the volatile anesthetic was then titrated down and turned off, and the patient was allowed to
emerge spontaneously with minimal manipulation. Once the patient was fully awake, with
spontaneous breathing and was able to meet the criteria, extubation was done.

The operation lasted for approximately 3 hours. There was no note of intraoperative
hypotension nor tachycardia. A total of 500cc of crystalloids was transfused, with around
100cc of blood loss. The patient’s vital signs were BP 130/70, HR 77, RR 18, SpO2 100% prior
transfer to the Post Anesthesia Care Unit for post-operative monitoring.

Post-operative medications given are as follows: 1) Ketorolac 30 mg IV ANST every 8 hours for
2 more doses, and is then shifted to, 2) Celecoxib 200 mg/cap, 1 cap PO every 12 hours for 7
days, 3) Paracetamol 600mg IV every 6 hours for 3 more doses, 4) Tramadol Drip (Tramadol
100mg + 98cc PNSS) to run for 8 hours at a rate of 12 gtts/min via soluset x 3 cycles, 5)
Tramadol 25 mg slow IV every 6 hours as needed for breakthrough pain, 5) Ondansetron 4 mg
slow IV every 8 hours x 3 doses then as needed for nausea or vomiting.

XIII. Post-operative Course

At immediate post-op, patient was GCS 15, awake with NRS of 0-1/10, not in cardiopulmonary
distress, with pinkish conjunctiva, symmetrical chest expansion and clear breath sounds, other
PE findings were unremarkable. Vital signs were BP 130/80, HR 70, RR 20, SpO2 100% with O2
at 2 lpm via nasal cannula.
 At 3 hours post-op, patient was still with stable vital signs with an NRS of 0/10 and was then
transferred back to wards.
At the wards at 24 hours and at 48 hours post-op, the patient was still GCS 15 with stable vital
signs, still NRS 0/10, without subjective complains, and with unremarkable PE findings.

XIV. Discussion
A. Breast surgery
Breast surgery is performed for a number of indications, including benign lump excision,
drainage of abscess, or cosmetic procedures, but the most common indication is for breast
cancer excision.

Breast surgery types:

Radical mastectomy, frequently performed 20 years ago, is now rarely indicated in modern
breast surgery. A number of landmark trials have proved the efficacy of breast-conserving
treatment (BCT), such as wide local excision of the tumor in addition to radiotherapy or
chemotherapy, in comparison to full mastectomy alone. This surgery requires a histological
confirmation that a minimum margin (typically 5 mm) of normal tissue has been excised
around the tumor. Contraindications to BCT include multifocal disease, inflammatory breast
cancer, and prior radiation to the breast.

Approximately 30% of patients require full mastectomy because of personal choice or their
unsuitability for BCT. Some patients wish to have prophylactic mastectomies for risk reduction
surgery, which can be simple, skin-sparing, or nipple-sparing mastectomy. Radical mastectomy
is reserved for tumors that invade the pectoral muscles.

Sentinel lymph node biopsy

Axillary lymph node dissection (ALND) has now been largely replaced by the minimally
invasive technique of sentinel lymph node biopsy (SLNB) for breast cancer staging. The
sentinel lymph node is the first node or group of lymph nodes that drains from the primary
cancer, and is therefore most likely to contain metastatic disease. Sentinel lymph node
mapping is usually carried out with a combination of radioisotopes and dye injected near the
tumour during surgery for removal of primary cancer. The lymph nodes (typically one to four)
with the highest radioactive signals will then be removed.

SLNB has been found to be equally effective at predicting the status of axillary lymph nodes
with far fewer adverse effects than ALND. These include lymphoedema (characterized by
painful swelling of the ipsilateral upper limb), upper limb sensory loss, increased length of
hospital stay, and prolonged time to recovery of normal activities. Women with positive SLNB
may require subsequent ALND and further adjuvant treatment.

SLNB is not without perioperative risk. Isosulfan blue and Patent Blue V are two of the primary
dyes used in SLNB; these have been associated with immunoglobulin E-mediated anaphylactic
reactions. These anaphylactic reactions can range from urticarial rash only to hypotension
requiring vasopressor support and even cardiac arrest.

The anesthetist should consider anaphylaxis to dye as a cause if there is an acute

cardiovascular event during SLNB breast surgery. Development of the one-step nucleic acid
amplification assay may allow the rapid detection of micrometastasis and could potentially
provide an alternative to pathology for examining SLNB.

B. Choice of Anesthetic technique

Procedures such as breast biopsy or augmentation, implant exchange, or completion of
transverse rectus abdominal muscle (TRAM) flap (i.e., nipple construction or revisions) are
routinely performed under general anesthesia. These surgeries entail separating the
pectoralis muscles from the chest wall, which is painful and usually requires GA.

The use of regional anesthesia with paravertebral nerve blocks has also been reported. Breast
surgery is associated with a high incidence of PONV; thus, it is likely that patients undergoing
breast surgery will require antiemetic medication in addition to postoperative analgesics.

Regional anesthesia in breast surgeries

Regional anesthetic techniques, usually combined with general anaesthesia (GA), have
become common in perioperative management of the patient for breast cancer surgery. The
use of thoracic paravertebral, pectoral nerve blocks (PECS) I and II, and serratus anterior (SA)
plane blocks are preferred techniques for breast surgery. Regional anaesthesia techniques
provide an excellent postoperative analgesia, an opioid sparing, and reduction in
postoperative nausea and vomiting (PONV).

Anesthetic Considerations
Jehova’s Witnesses
Nearly all Jehovah’s Witnesses refuse transfusions of whole blood (including preoperative
autologous donation) and the primary blood components – red cells, platelets, white cells and
unfractionated plasma. Many Witnesses accept the transfusion of derivatives of primary
blood components such as albumin solutions, cryoprecipitate, clotting factor concentrates
(including fibrinogen concentrate) and immunoglobulins.

To provide optimal care for patients who are Jehovah’s Witnesses, surgeons and
anesthesiologists should aim to respect and accommodate each patient’s values and target
the best outcome possible given the patient’s desires and his/her clinical condition.

Fortunately, blood transfusion is only rarely required for most of breast surgeries.
C. General Anesthesia
Review of airway anatomy
Upper Airway
The pharynx is the mucous membrane-lined portion of the airway between the base of the
skull and the esophagus and is subdivided as follows:
• Nasopharynx, also known as the rhino-pharynx, post-nasal space, is the muscular tube
from the nares, including the posterior nasal cavity, divide from the oropharynx by the
palate and lining the skull base superiorly
• The oro-pharynx connects the naso and hypopharynx. It is the region between the
palate and the hyoid bone, anteriorly divided from the oral cavity by the tonsillar arch
• The hypopharynx connects the oropharynx to the esophagus and the larynx, the
region of pharynx below the hyoid bone.
The larynx is the portion of the airway between the pharynx and the trachea, contains the
organs for the production of speech. Formed of a cartilaginous skeleton of nine cartilages, it
includes the important organs of the epiglottis and the vocal folds (vocal cords) which are the
opening to the glottis.

Lower Airway
The trachea is a ciliated pseudostratified columnar epithelium-lined tubular structure
supported by C-shaped rings of hyaline cartilage. The flat open surface of these C rings
opposes the esophagus to allow its expansion during swallowing. The trachea bifurcates and
therefore terminates, superior to the heart at the level of the sternal angle.

The bronchi, the main bifurcation of the trachea, are similar in structure but have complete
circular cartilage rings.
• Main bronchi: There are two supplying ventilation to each lung. The right main
bronchus has a larger diameter and is aligned more vertically than the left
• Lobar bronchi: Two on the left and three on the right supply each of the main lobes
of the lung
• Segmental bronchi supply individual bronchopulmonary segments of the lungs.

The trachea divides at carina into the right and left main bronchus. The distance of the carina
from the teeth varies markedly with change in neck position from flexion to extension
(tracheal length variation is ± 2 cm), body position and position of diaphragm. This explains
the change in position of endotracheal tube during change in position of patient or flexion –
extension of neck.

The right main stem bronchus has a more direct downward course, is shorter than the left and
begins to ramify earlier than the left main bronchus. This leads to higher chances of right
endobronchial intubation. The right main stem bronchus divides into (secondary bronchi) right
upper lobe bronchus and bronchus intermedius which further divides into right middle and
lower lobe bronchus.

The left bronchus passes inferolaterally at a greater angle from the vertical axis than the right
bronchus. The left main stem bronchus divides into (secondary bronchi) the left upper and
lower lobe bronchi.

Sensory innervation
The upper airway is divided into the nasal and oral cavities, the pharynx, and the larynx. The
sensory innervation to the upper airway is supplied by the trigeminal, glossopharyngeal, and
vagus nerves
The nose is entirely innervated by branches of the trigeminal nerve. Septum and anterior parts
of the nasal cavity are affected by the anterior ethmoidal nerve (a branch of the ophthalmic
nerve). The rest of the nasal cavity is innervated by the greater and lesser palatine nerves
(branches of the maxillary nerve).

The palatine nerves are relayed through the pterygopalatine ganglion, found in the
pterygopalatine fossa, which is situated close to the sphenopalatine fossa, located just
posterior to the middle turbinate.

The pharynx is largely innervated by the glossopharyngeal nerve. Innervation of the whole
pharynx, posterior third of tongue, the fauces, tonsils, and epiglottis is from the
glossopharyngeal nerve. The oropharynx is innervated by branches of the vagus, trigeminal,
and glossopharyngeal nerves.

The larynx is innervated by the vagus nerve. Above the vocal cords (base of tongue, posterior
epiglottis, aryepiglottic folds, and arytenoids), the internal branch of the superior laryngeal
nerve (a branch of the vagus nerve) supplies innervation. For the vocal cords and below the
vocal cords, the recurrent laryngeal nerve (a branch of the vagus nerve) is the supplier.

Because the recurrent laryngeal nerves supply all of the intrinsic muscles of the larynx (with
the exception of cricothyroid muscle), trauma to these nerves can result in vocal cord
dysfunction. With unilateral recurrent laryngeal nerve injury, hoarseness is the primary
symptom, though the protective role of the larynx in preventing aspiration may be
compromised. Bilateral injury can result in complete airway obstruction due to fixed cord
adduction and may be a surgical emergency.

Conduct of anesthesia
We start the induction of anesthesia with preoxygenation. Preoxygenation or otherwise
known as ‘denitrogenation’

Preoxygenation
entails the replacement of the nitrogen volume of the lung (as much as 95% of the functional
residual capacity) with oxygen in order to provide an apneic oxygen reservoir.

Under ideal conditions, a healthy patient breathing room air (FIO2 = 0.21) will experience
oxyhemoglobin desaturation to a level of less than 90% after approximately 1 to 2 minutes of
apnea. In the same patient, several minutes of preoxygenation with 100% O2 via a tight-fitting
facemask may support at least 8 minutes of apnea before desaturation occurs.

Proxygenation is done with: 1) tight fitting mask, 2) 100% O2 at 10-12 lpm, and with the ff:
 Tidal Volume Preoxygenation for 5 minutes or more with tidal volume
breathing
Vital Capacity 4 vital capacity breaths for over a 30-second period
*Modified Vital Capacity 8 deep breaths in a 60-second period
*The modified vital capacity preoxygenation was done in this case

Slow sequence induction

Slow sequence induction was done with the following medications
Medication IV dose Onset Duration Be aware
Fentanyl 1-2 mcg/kg 1-2 min 30 min Hypotension
Propofol 1-2.5 mg/kg 10-20 sec 10-15 min Hypotension
Atracurium 0.5 mg/kg 2 min 40-45 min Histamine release

Fentanyl is an opioid and is used to blunt the sympathetic response to intubation (e.g.
hypertension, tachycardia). It can cause vagus nerve mediated bradycardia with large doses.

Propofol is a GABA agonist to induce hypnosis and to facilitate intubation. It decreases arterial
blood pressure due to a drop in SVR, preload & cardiac contractility. It induces apnea thus
ventilation is required in this case, once a muscle relaxant for slow induction is given.

Atracurium is an intermediate-acting non-depolarizing muscle relaxant, and is the relaxant of

choice for this case. It is used to provide adequate intubating conditions. It is mainly
metabolized by nonenzymatic degradation (Hofmann elimination) and also by ester
hydrolysis. Adverse reactions to atracurium are associated to histamine release. The most
common side effects associated with histamine release are flushing and erythema. However,
there are no contraindications in using atracurium with this patient.

Positioning
Careful positioning must be done once positioning the patient for breast surgery.

A recommendation is to limit the abduction of the upper limb to 90°, and in this situation to
maintain the head in a neutral position, with no lateral displacement, since cadaveric studies
have demonstrated a greater tension of the brachial plexus when the head is turned. Another
is the use cushioned arm supports to prevent injury to the peripheral nerves.

Iatrogenic injury to the brachial plexus is an uncommon occurrence in breast surgery, and its
exact incidence is unknown because most authors have published isolated cases of
neurological injury. Breast surgery presents factors for the appearance of paralysis of the
brachial plexus; oncoplastic and reconstructive procedures are characteristically long in
duration and involve postural changes as well as the need for positioning the upper limbs in
abduction.

D. Analgesia
The WHO analgesic ladder specifies treatment on pain intensity, from simple analgesics for
mild pain to opioid analgesics for moderate and severe pain. Its three steps are:
• Step 1 Non-opioid plus optional adjuvant analgesics for mild pain;
• Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to moderate pain;
• Step 3 Strong opioid plus non-opioid and adjuvant analgesics for moderate to severe
pain.
It is advised to move up one step when there is persistent pain. In case of toxicity or severe
adverse effects, providers are advised to either reduce medication doses or move down one
step. The ladder provides five simple recommendations for the usage of analgesics: by mouth,
by clock, by ladder, by individual and attention to the detail. Just two years following its
release, it was already validated in 80–90% of cases.

The stepwise approach had tremendous value when it was introduced for its conservative and
simple principles for pain management, which could be applied everywhere in the world, even
in those underdeveloped countries with fewer pain management specialists. It has been of
significant benefit for the control of pain worldwide. Until now, this guideline has remained
applicable, not only in cancer pain management but also for acute pain and chronic pain
requiring analgesics.
 Total abdominal hysterectomy and bilateral salpingo-oophorectomy is frequently associated
with severe or postoperative pain, thus intrathecal opioids is warranted. With reference to the
WHO Analgesic ladder, my multi-modal post-op pain regimen is structured as follows:
NSAIDs 1) Ketorolac 30 mg IV ANST every 8 hours for 2 more doses, and is
then shifted to,
2) Celecoxib 200 mg/cap, 1 cap PO every 12 hours for 7 days
Non-opioids 3) Paracetamol 600 mg IV every 6 hours for 3 more doses
Opioids 4) Tramadol Drip (Tramadol 100mg + 98cc PNSS) to run for 8 hours
at a rate of 12 gtts/min via soluset x 3 cycles

5) Tramadol 50 mg slow IV every 6 hours as needed for breakthrough

pain
Anti-emetic *5) Ondansetron 4 mg slow IV every 8 hours x 3 doses then as
needed for nausea/vomiting
*Anti-emetic for the side effects of tramadol

A multimodal approach to pain management allows administration of lower doses of various

medications and less dense regional anesthesia techniques than would be required otherwise,
and would therefore result to reduced side effects and complications.

XV. References
1. Barash, P., et al. (2017) Clinical Anesthesia, 8th edition
2. Sherwin A, Buggy DJ. Anaesthesia for breast surgery. BJA Educ. 2018 Nov;18(11):342-348.
doi: 10.1016/j.bjae.2018.08.002. Epub 2018 Sep 27. PMID: 33456800; PMCID:
PMC7807849. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807849/
3. Ahmad, Imran. NYSORA: Regional and Topical Anesthesia for Awake Endotracheal
Intubation. Accessed at: https://www.nysora.com/techniques/head-and-neck-
blocks/airway/regional-topical-anesthesia-awake-endotracheal-intubation/
4. Acea Nebril B, Domenech Pina E, Díaz Carballada C, García Novoa A. Lesiones del plexo
braquial en la cirugía mamaria. Recomendaciones para su prevención. Cir Esp.
2016;94:251–253. Accessed at: https://www.elsevier.es/en-revista-cirugia-espanola-
english-edition--436-articulo-brachial-plexus-lesions-in-breast-S2173507716300138
5. Anekar AA, Hendrix JM, Cascella M. WHO Analgesic Ladder. [Updated 2023 Apr 23]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK554435/