Consider Epidural Anesthetic as an Adjunctive or Primary Technique for Patients Having Mastectomy
Jennifer Vookles MD, MA
Mastectomies are commonly performed under general anesthesia; however, various regional anesthetic techniques for breast surgery have been evaluated to serve as the primary anesthetic, the adjunctive anesthesia, or the postoperative analgesia, or to serve as a combination of these roles. Examples of these techniques include field local infiltration, brachial-plexus blocks, paravertebral blocks, intercostal nerve blocks, and thoracic epidural anesthesia.
These different approaches have a wide range of utility. At one extreme, local infiltration is very limited and could only be used as the sole anesthetic choice for more confined surgeries. Also, the benefits of local anesthesia as well as of some of the peripheral nerve blocks cannot be extended beyond the duration of the local anesthetic effect. At the other extreme, thoracic epidural analgesia (TEA) can be used as the sole anesthetic for extensive breast procedures and can provide prolonged postoperative pain control via continuous infusion. Use of TEA obviates the need for using volatile anesthetics and opioid analgesics, and, as a result, less postoperative nausea and vomiting and shorter recovery times have been reported with TEA use. Even using TEA as an adjunct to a general anesthetic can provide substantial benefits. Using TEA and a local anesthetic selectively blocks cardiac sympathetic fibers, resulting in greater hemodynamic stability, improved myocardial oxygen balance, and an attenuated stress response. Pre-emptive analgesia may also play a role in decreasing postoperative pain and opioid requirements. Greater patient satisfaction has been reported.
Yeh and Doss both used TEA for their primary anesthetic plus sedation. They placed catheters at a T5-6 or T6-7 level and threaded catheters 3 to 5 cm into the epidural space. One reports maintaining a block between C5-T6 with 2% lidocaine; the other reports maintaining a block from roughly 2 cm below the clavicle and to the costal arch inferiorly with 0.2% ropivacaine. Both approaches were successful, although, in some patients, the surgeons needed to supplement with local anesthetic during the axillary-node dissection.