Antibiotics optional, cefazolin 1 g IV (dose: 80 kg = 2 g)

ExtraThoracic Surgery Flashcards by Linsay AugustinCRNA

Different types of Extrathoracic Surgery

Breast biopsy/lumpectomy
Sentinel lymph node biopsy
Mastectomy
Mastectomy with reconstruction
Clavicle repair

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Breast biopsy/lumpectomy Terminology

Excisional biopsy = benign

* Lumpectomy = cancerous lesion

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Patient population
Lumpectomy =_____(age)
wire-localized breast biopsy =___(age)
Mainly what sex (M/F)

> 15 yr ; 25-90 yr; female

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Palpable lesions characterized by

masses, nodules, asymmetric thickening

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•Breast biopsy/lumpectomy manifestations

edema, redness, brawny discoloration, ulceration

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• Bloody/pathological nipple discharge

Usually benign intraductal papilloma

* Rarely carcinoma

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Percutaneous Hookwires in breast Using 2 imaging studies? Explain

MRI and breast US.
Radiologist places Percutaenous hook-wires close to lesion
Surgeon removes breast tissue surrounding wire
Confirm removal of wire and target lesion with radiography and ultrasound

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Paravertebral block put at risk for

pneumothorax

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Block for lumpectomy

• Factors to pick a block

• Paravertebral block
• With MAC or GA
• Pectoral nerve block type II
size, location, quantity, trajectory of wires, patient preferences

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ABT breast surgery

Antibiotics optional, cefazolin 1 g IV (dose: < 80 kg =

1 g, > 80 kg = 2 g)

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Breast surgery closing

Closing specimen radiograph result must be

obtained

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Breast surgery approx time

Pain

Time 0.5-1.5 h

2-5

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M and M of breast surgery

M/M seroma, ecchymosis, hematoma, infection

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Sentinel lymph node biopsy

Most likely node?

Invasive breast cancer without pathologic lymph nodes
• Most likely node to FIRST harbor metastatic tumor cells
• No metastasis means no cells = other lymph nodes
negative for CANCER

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• SNL =

first node to drain afferent lymphatics from a particular region of breast. Therefore

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Lymphatic mapping

What should surgeon tell anesthesiologist?

• Dyes
• Drops SpO2 (2-5% 20-25 min after injection)
Injected (clock plane , 6, 12, 9, 3)

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Sentinel node biopsy

No paralyzing, no muscle relaxants.

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Technetium sulfur colloid (TSC)

Low radiactive tracer

No additional protection required

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Unique considerations BP

BP cuff cannot be an operative side, ask about muscle relaxation.

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SNL antibiotics

Cefazolin 1g

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SNL EBL, SNL timing

Minimal
10-30 min but up to 1.5 h with axillary lymph node
dissections

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M and M with SNL

Allergic reaction to dyes

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Anesthesia considerations for breast biopsy/SNL

Pre-Op

• Anxious, require midazolam, lab testing not always necessary (except HCG if child-bearing age)

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Anesthesia considerations for breast biopsy/SNL

Intra-OP

MAC: Propofol 25-100 mcg/kg/min, supplement with fentanyl/remi and midazolam, titrate to effect
REMI bolus: 0.5-1mcg/kg 90 seconds prior to initial incision with local anesthesia
Consider HIGH Propofol

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If concerns about HR for Breast biopsy

Give Glycopyrrolate (Robinul)

• GA:

may mask or LMA if appropriate • Standard induction, maintenance, emergence • Isosulfran dye reaction = pruritus, localized swelling, blue hives • Diphenhydramine 10 -50mg IV, epi if BP ↓

• Postoperative •

Urine, emesis, or stool might be blue for 24 -48h

• Immediate breast reconstruction | 2 types

``` • Usually not if postop chest radiation needed Two types: • Prosthetic reconstruction • Autologous myocutaneous flap ```

Position for mastectomy , total and lumpectomy

Supine, ipsilateral arm abducted

Mastectomy time

1.3- 3 hours long

EBL mastectomy

150-500ml lumpectomy is 25-100ml

Morbidity and mortality

LYMPHADEMA SEROMA INFECTION Nerve damage

Axillary part of the surgery consideration

NO PARALYTICS

Antibiotics for modified radical, lumpectomy and total

Cefazolin 2g IV

• Preop Mastectomy • Resp: •

hx radiation therapy to chest = compromise; | CXR if any pulmonary signs

Preop Mastectomy Cardio:

Chemo agents can cause cardiomyopathy, | order diagnostic studies if presentation indicates

Preop mastectomy Neuro:

breast CA can mets to CNS (focal neuro deficits, ↑ICP, AMS)

Preop Mastectomy Hem:

Anemia/thrombocytopenia associated with chemo

Doxorubicin associated with

CARDIOMYOPATHY

Post op Emergence =

may require binder in sitting position = keep them asleep through this process

Post op considerations: ASk about

Binder (keep asleep till then)

Multilevel paravertebral blocks level MASTECTOMY

T1- T6

How many ml per level

• 4-5 mL/leve

2 local anesthetics you can use for mastectomy

Bupivacaine :0.5% | Ropivacaine 0.5%

Contraindications to regional anesthesia

Contraindications: patient refusal, local anesthetic allergy, pathology or anatomical distortion of paravertebral space, infection at site

Anesthetic considerations Post Op complications | and symptoms

``` Complications: pneumothorax • Symptoms? • Others (2° PNB) **** Failed block (10%) ****Pleural puncture **** Pneumothorax (PIP goes up, CO2 goes down) **** Horner’s syndrome • Accidental epidural spread of local anesthetic • PONV ```

Pneumothorax interventions

O2 100 FiO2 Chest Xray Remove Positive pressure ventilation

Signs of Pneumothorax

breath sounds decreased on one side | Avoid Positive pressure ventilation

Horner's syndrome

Ptosis, myosis droops on side LA was injected.

Tips for breast surgery

Know local anesthesia toxicity levels • OR table may be angled/turned sideways (Disconnect ET before moving) • Breast biopsies can turn into mastectomy

LA toxicity

Serum levels , LA in tissue doesn't always transfer to vessels.

Lidocaine with epi

7mg/kg

Lidocaine without epi

4mg/kg

LTA (laryngotracheal Topical Anesthesia)

4ml 4%

Lidocaine and marcaine

Additive effects, Consider both can increase toxicity

Interscalene Block

Clavicle

Clavicle repair | Position

Beach chair or supine, head turned away from surgical field, bump placed behind affected shoulder (ANNOYING) HOLD HEAD entire time

Unique considerations

* RSI if trauma * ISB will NOT help cover proximal clavicular pain * IV/cuff on nonoperative side

Clavicle repair GETA or

GETA or GLMAA | • Tape tube on one side opposite of surgical field

Clavicle repair

Surgeon may require SBP < 100 mm Hg to prevent | bleeding

Complications of clavicle repair

Complications: brachial plexus or subclavian artery | injury

Eye protection is important

``` • Tape eyes closed, place pads over eyes, consider goggles (DON’T) ```

• Perform a thorough distal neuro assessment on

the affected arm both pre/post | • Circulation, sensation, motor function

For beach chair Carefully stabilize

head in beach chair position • Tape the ETT or LMA SEVERELY • Head will be under drapes

Ductoscopy

Give surgeon clear view between diseased and healthy breast tissues (camera into milk duct)

If unable to find SNL

conventional axillary dissection level I and II

Lumpectomy, axillary LND pain score and Morbidity | Post op care if no morbidity

4-8PACU → 2 d hospitalization | PACU--> Home

Lumpectomy, axillary LND pain score and Morbidity | Post op care if no morbidity

4-8PACU → 2 d hospitalization | PACU--> Home

ExtraThoracic Surgery Flashcards

(68 cards)