American Society of Regional Anesthesia and Pain Medicine May 2018 - 14

Problem-Based Learning Discussion (PBLD): Pain Management in
Patients Undergoing Mastectomy and Axillary Surgery
Editor's note: We encourage submissions of deidentified cases for discussion in future issues. Send cases to asranewseditor@
asra.com. Would you like to share your opinions on cases? Send your name, practice setting, and contact information to
asranewseditor@asra.com.

A

68-year-old woman presents for bilateral mastectomy with
sentinel lymph node biopsy and possible axillary dissection. She
suffers from hypertension, diet-controlled diabetes, obstructive
sleep apnea, and obesity (120 kg, body mass index is 37). Medications
include lisinopril and metoprolol. The patient's blood pressure is well
controlled, her hemoglobin A1C is 5.6%, and she has been medically
optimized by her primary care provider.
What multimodal analgesic plan would you normally use for
this patient?
Warren: At my institution, the typical multimodal analgesic plan for this
patient would include acetaminophen, opioids, and local anesthetic
infiltration performed by the surgeon. Our surgeons typically instill local
anesthetic through the drain and clamp the drain for an hour, after
which the clamp is released. Patients are quite comfortable and do
well. Our practice is to only perform paravertebral blocks for patients
having additional immediate reconstruction, but on occasion for select
patients we will also perform paravertebral or pectoralis nerve and
serratus plane (PECS) blocks for simple mastectomy/axillary dissection.
We also consider the use of perioperative gabapentin and celecoxib.

Kristopher Schroeder, MD
Associate Professor
School of Medicine and Public Health
University of Wisconsin
Madison, Wisconsin

Pawa: At my institution, we have not implemented the preoperative
administration of multimodal analgesics (acetaminophen,
nonsteroidal anti-inflammatories, and gabapentinoids) despite
having a large breast cancer caseload. I would therefore not
administer anything preoperatively. My primary concerns here
would be that her diabetes is controlled and that she omits her
lisinopril on the day of surgery.
Feinstein: In the preoperative holding area, this patient would be
offered a standardized oral multimodal regimen based on age and
pertinent lab findings. The medications include gabapentin 800 mg
(800 mg for those younger than 69 years and 400 mg for those
older than 69 years); acetaminophen 1,000 mg; and celecoxib 400
mg (if GFR greater then 60 mL/min/1.73 m2, 400 mg for those
younger than 69 years and 200 mg for those older than 69 years).
The patient would also be offered a single-injection interfascial
plane block prior to surgery.
What is your anesthetic plan for this patient? Do you need any
additional information to formulate your plan?
Warren: I would like to have more information about the patient's
functional status, and at least a recent echocardiography test to
review. I would confirm that her blood pressure is well controlled

14

American Society of Regional Anesthesia and Pain Medicine
2018

Melanie Donnelly, MD
Associate Professor
University of Colorado
Aurora, Colorado



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