Mastectomy + Axillary Lymph Node Dissection
Patient phenotype
Breast cancer, often middle-aged to elderly female. Some on neoadjuvant chemo (cardiotoxic anthracyclines, capecitabine). Often anxious. Comorbidities variable. May be combined with immediate reconstruction.
Procedure
Simple mastectomy: 1-2 hours. Modified radical (with axillary): 2-3 hours. Sentinel lymph node biopsy with radiotracer + blue dye. Supine, arm out on board.
Anesthetic plan
GETA. Pec I/II or serratus anterior plane block (PECS, ESP) for postop analgesia — opioid-sparing. Avoid BP cuff/IV on operative side. Watch for blue dye reactions (anaphylaxis, blue urine).
Setup
- ·Standard monitors + temp
- ·1-2 PIVs (contralateral arm only)
- ·BP cuff contralateral
- ·Type & screen
- ·Forced air warmer (lower body)
- ·Pec block kit if doing regional
Biggest concerns by phase
Chemo cardiotoxicity assessment
Anthracyclines (doxorubicin) cumulative cardiotoxicity → cardiomyopathy. Recent echo if ≥ 240 mg/m² doxorubicin or symptoms. Trastuzumab also cardiotoxic. Continue beta-blocker if HF.
Avoid operative side access
Lymphedema risk lifelong if axillary nodes removed. NO BP cuff, NO IV, NO blood draw on operative side — even after the case. Sign in chart.
Methylene blue / isosulfan blue reactions
Sentinel node tracer (isosulfan blue) → 1-2% allergic reaction (anaphylaxis). Pulse ox reads falsely low (blue dye). Urine turns blue 24h. True hypoxia hard to assess by SpO2 — confirm with ABG if concerned. Methylene blue (alternative) interferes with serotonin syndrome in patients on SSRIs.
Pec/ESP block — opioid-sparing analgesia
Pec I (between pec major + minor) + Pec II (between pec minor + serratus) cover anterior chest. ESP (erector spinae) covers chest wall + axilla. 20-30 mL ropivacaine 0.5%. Reduces postop opioid 50%.
PONV + smooth emergence
Female + breast surgery + opioid = high PONV. Multimodal antiemetic. Smooth emergence — coughing on surgical bed = hematoma risk in flap.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-yo F with R breast cancer on neoadjuvant doxorubicin + trastuzumab (last dose 4 wks ago), prior LV EF 55. Mastectomy + ALND scheduled. Plan?
What an examiner probes for
- ▹Echo verification post-chemo
- ▹Cardioprotective: continue beta-blocker, statin
- ▹Pec/ESP block for analgesia
- ▹Avoid R arm access permanently
- ▹Blue dye reaction preparedness
Sources
- Miller's Ch 71
- ASRA Pec Block Review
- Society of Surgical Oncology Guidelines
Anatomy reference
Sourced reference images. 4 matches for "breast chest axilla lymph".
