American Society of Regional Anesthesia and Pain Medicine May 2018 - 15

Contributors:

Lisa Warren, MD
Assistant Professor of Anesthesia
Massachusetts General Hospital
Boston, Massachusetts

Amit Pawa, BSc(Hons) MBBS(Hons) FRCA EDRA
Consultant Anaesthetist and Regional Anaesthesia Lead
Guy's & St Thomas' NHS Foundation Trust
London, United Kingdom

and that she has no unstable cardiovascular symptoms and no
evidence or history of congestive heart failure. If her functional
status is limited, I would want to review a recent stress test or
transthoracic echo. In addition, I would ask whether she uses
continuous positive airway pressure (CPAP) machine regularly,
and if she had any previous anesthetic-related issues or history/
symptoms of significant gastrointestinal reflux disease. I would
include a thorough exam of the airway and auscultation of heart
and lungs in my physical assessment.
Pawa: I would use my standard practice for mastectomy and
axillary surgery and perform general anesthesia maintained by
total intravenous anesthesia with a target-controlled infusion of
propofol. For this patient, I would intubate the trachea to secure
her airway. Analgesia would be delivered by siting bilateral
single-shot, single-level paravertebral blocks, possibly with the
addition of bilateral PECS blocks. I would be keen to minimize
administration of any opiates. Prior to siting the paravertebral
blocks, I would like to know whether the patient was on any
antiplatelet or anticoagulant drugs or whether she had any other
potential contraindications to siting them. It would be useful to
know the severity of the obstructive sleep apnea and her reliance
on CPAP so that I could plan her postoperative destination. In
all likelihood, I would request a high-dependency bed for her
postoperative recovery. Finally, it would be useful to know how
well her diabetes and blood pressure were controlled and whether
she had any evidence of end-organ damage.
Feinstein: If no other information was revealed during a
preoperative assessment, the patient would receive an interfascial
plane block and general anesthesia with an endotracheal tube
for this surgery. If the patient was not a candidate for regional
anesthesia, a lidocaine infusion would be used throughout the case.

Joel Feinstein, MD
Assistant Professor
University of Alabama
Birmingham, Alabama

What pharmacologic agents would you choose for maintenance
of general or monitored anesthesia?
Warren: My general anesthetic plan would be either total
intravenous anesthesia with propofol or a volatile anesthetic
with sevoflurane and possibly nitrous oxide. I might also
consider using low-dose ketamine to potentially reduce opioid
use. I do not use remifentanil infusions and rather administer
a long-acting opioid during the case. Neuromuscular blockade
would most likely be obtained with succinylcholine followed
by rocuronium. A monitored anesthesia care (MAC) protocol
might include low-dose propofol, midazolam, and fentanyl.
Dexmedetomidine is another option during MAC, although not
one that I personally use.
Pawa: My general anesthesia would be maintained by a targetcontrolled infusion of propofol, guided by a depth of anesthesia
monitor such as the bispectral index. The choice of drug is largely
based on the work from two studies.1,2
If the patient was amenable and motivated, I would consider
using the propofol infusion as MAC. Our group has published our
experience with this perioperative strategy.3
Feinstein: Unless she has significant comorbidities that warrant
avoidance of general anesthesia, the patient would be induced
with lidocaine, fentanyl, propofol, and succinylcholine. Our
surgeons request that no long-acting muscle relaxants be used
in the setting of axillary dissection. Dexamethasone would
be given shortly after induction as prophylaxis for nausea.
Anesthesia would be maintained with sevoflurane in an airoxygen mixture. Near emergence, the patient would also receive
ondansetron.

American Society of Regional Anesthesia and Pain Medicine
2018

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2018