• This pathway targets a reduced stress response to surgery and aims for a complication-free recovery, thereby shortening hospital stay for patients.

• To provide a standardised care pathway for patients undergoing mastectomy, ensuring high quality anaesthesia and multi-modal analgesia is delivered.

• Specific considerations for this patient group:

  • High rates of post-operative nausea and vomiting
  • Significant acute pain, leading to prolonged hospital stay
  • High rates of chronic pain, leading to reduced quality of life
  • Current evidence suggests that inhalational anaesthetic agents and opioid-based analgesia may have adverse effects on cancer outcomes

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

1.1 Effective analgesia is crucial to patient outcome after major surgery to ensure comfort, early mobilisation and decreased risk of potential post-operative complications such as VTE disease and respiratory tract infections.

1.2 The British Association of Day Surgery (BADS) expectation for mastectomy surgery is that 75% can be performed as a day case, with the remaining cases requiring a one night stay.

1.3 As surgical techniques change and length of inpatient stay decreases, it is important to offer a safe, flexible method of analgesia which may be delivered in both a hospital and community environment if necessary.

1.4 Regional anaesthetic techniques for mastectomy have been shown to provide effective pain relief, thereby reducing opioid requirement, with consequent decrease in their side effects.

1.5 This document outlines the anaesthetic peri-operative management of patients undergoing mastectomy. This includes the use of serratus anterior interfascial plane catheters and ambulatory infusions of local anaesthetic

2.1 Medical staff:

• Peripheral nerve and interfascial plane blocks must be delivered by staff competent in the technique, either as a single injection or catheter placement for continuous infusion

• Staff must be aware of contraindications to regional anaesthetic procedures

• Staff must be familiar with and be able to manage complications that can occur as a result of a regional anaesthetic technique

• It is expected that staff have the appropriate knowledge of full aseptic technique, intravenous cannulation and resuscitation skills, as well as knowledge of the pharmacology of the drugs being used together with treatment of potential side effects

2.2 Nursing staff

• Staff must be aware of the potential side effects and complications of local anaesthetic infusions and how to manage these. It is assumed that nurses with training for care of epidurals and knowledge of the side effects and potential signs of toxicity will be able to care for patients with peripheral local anaesthetic infusions

• Timely observations are necessary for the safe delivery of this method of analgesia. All observations will be recorded on the FHFT Regional Anaesthesia observation chart which combines the regular observations of vital functions (RR, BP, HR, oxygen saturation and urine output) with those more specific parameters and scores necessary for safe and effective local anaesthetic delivery

For full guidance on the management of continuous local anaesthetic infusions see the related documents section.

3.1 Pre-operative

• Breast surgeons, in the clinic environment, will provide information regarding peri-operative care, including the use of serratus anterior interfascial plane catheters for continuous local anaesthetic infusion

• Pre-assessment nurses will provide patient information on the ambulatory pathway, which includes information on local anaesthetic infusion pumps

• The anaesthetist responsible for the patient’s care will pre-assess the patient on the morning of surgery unless any specific concerns have been raised at the surgical assessment and nurse-led pre-assessment

• A VTE assessment should be completed, with a plan for post-operative VTE prophylaxis

3.2 Intra-operative

• Normothermia is maintained using an underbody warming mattress and warmed intravenous fluids

• A regional anaesthetic technique is recommended, either with the patient awake or asleep, as decided by the anaesthetist. Regional anaesthesia options include:

  • Pectoral nerve blocks (PECS 1 and PECS 2)

  • Thoracic paravertebral (TPVB)

  • Serratus anterior plane block

  • Erector spinae plane block (ESP)

The choice of which regional anaesthetic technique to perform is influenced by patient, surgical and anaesthetic factors. Current evidence suggests that either a TPVB or a chest wall interfascial plane block, such as PECS 1 and PECS 2, is appropriate for mastectomy.

Where a regional anaesthetic technique is not performed by the anaesthetist, the surgeon will perform the appropriate fascial plane blocks during surgery.

• General anaesthesia using total intravenous anaesthesia (TIVA) technique is recommended

• In addition to regional anaesthesia, a multimodal opioid-sparing analgesic approach should be delivered (note – some indications and doses may be off-label):

  • Paracetamol 1g IV (or 15mg/kg if the patient’s weight is less than 50kg) if not already administered prior to anaesthesia

  • Ketorolac 30mg or Parecoxib 40mg IV if NSAID has not already been administered prior to anaesthesia and no contraindications

  • Consider use of Alpha 2 agonists, for example Clonidine (50 micrograms)

  • Consider use of Magnesium Sulphate (2g diluted in 100ml 0.9% Sodium Chloride and given over at least 20 minutes)

• Dual anti-emetic treatment of Dexamethasone 6.6mg and Ondansetron 4-8mg IV should be given (unless contraindicated)

• 1g of Tranexamic acid IV should be administered

• Surgically inserted serratus anterior plane catheter

  • The surgeon should place a serratus anterior plane catheter at the end of surgery (video of catheter insertion on Trust moodle)

  • The anaesthetist or scrub team will prepare the elastomeric local anaesthetic infusion pump solution (Appendix- follow FHFT SOP on Elastomeric Local Anaesthetic Pump preparation instructions)

• Elastomeric pump filled with 400ml 0.125% Levobupivacaine in sterile conditions

• Connect to patient prior to transfer to Post Anaesthetic Care Unit (PACU)

3.3 Post-operative management

• Regular paracetamol and NSAID should be prescribed (if there are no contra-indications)

• Avoid regular opioids

• As required medication should be prescribed in line with day case guidance:

  • Breakthrough pain - intravenous fentanyl in PACU, oral morphine up to 20mg 2-hourly thereafter.

  • Elderly or frail – review morphine dose

  • Impaired renal function – consider alternative to morphine

  • Antiemetics - ondansetron, cyclizine and metoclopramide PO/IV (if no contraindications)

• Post-operative fluids should not be prescribed as routine

• VTE prophylaxis should have been prescribed as per Trust guidance

• The patient should be discharged home with an adequate supply of multimodal analgesia for regular and breakthrough pain

Elastomeric local anaesthetic pump via serratus anterior plane catheter

• 0.125% Levobupivacaine at a rate of 6mls/ hour should be prescribed and attached via the serratus anterior plane catheter

• Monitoring and the postoperative management of all patients undergoing infusions of local anaesthetic should adhere to the Trust policy (see related documents)

• Advice on pain management and interfascial plane catheters should be sought from the anaesthetist responsible for the patient in the first instance. Thereafter, advice can be obtained from the 5002 anaesthetic bleep holder or the inpatient pain team (bleep 5252).

• All patients with a serratus anterior interfascial plane catheter should be reviewed daily (until its removal) by the inpatient pain team while the patient remains in hospital. The catheter insertion site should be assessed and monitored for any complications. The catheter and pump should be removed after 48 hours.

• If the surgical team is happy, the patient can be discharged home the same day with the serratus anterior catheter in situ and delivering continuous local anaesthetic

• The patient’s discharge summary must give instructions about ongoing serratus anterior interfascial plane catheter management:

  • Handover and follow-up instructions to the district nurse for the removal and disposal of the catheter and pump at 48 hours

  • Information regarding the Elastomeric pump

  • Emergency contact details of the anaesthetic department, surgical hotline and breast specialist nurse

• Patient information leaflet

  • Information regarding the Elastomeric pump

  • Red flag symptoms and how to stop/disconnect in emergency

  • Emergency contact details of the anaesthetic department, surgical hotline and breast specialist nurse

• Video of Insertion of serratus anterior interfascial plane catheter and the how to fill of the Elastomeric pump (available on Trust moodle)

1. Bailey, C. R. et al. (2019) Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery. Available at: https://doi.org/10.1111/anae.14639 (Accessed: 03 March 2025).

2. British Association of Day Surgery (2022) BADS Directory of Procedures & National Dataset. Available at: https://publications.bads.co.uk/bads-directory-of-procedures--national-dataset-1-p.asp (Accessed: 03 March 2025).

3. Sherwin, A. and Buggy, D.J. (2018) ‘Anaesthesia for breast surgery’, BJA Education, 18(11), pp. 342-348. Available at: https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext (Accessed: 03 March 2025).

4. Terkawi, A. S. et al. (2015) ‘Improving analgesic efficacy and safety of thoracic paravertebral block for breast surgery: a mixed-effects meta-analysis’, Pain Physician, 18, E. 757 - E 780. Available at: https://www.painphysicianjournal.com/current/pdf?article=MjQwNg%3D%3D&journal=91 (Accessed: 03 March 2025).

5. Bashandy, G. M. N. and Abbas, D. N. (2015) ‘Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial’, Regional Anesthesia and Pain medicine, 40(1), pp. 68-74. Available at: https://doi.org/10.1097/aap.0000000000000163 (Accessed: 03 March 2025).

6. Kulhari, S. et al. (2016) ‘Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial’, BJA, 117(3), pp. 382 - 386. Available at: https://www.bjanaesthesia.org/article/S0007-0912(17)33800-X/fulltext (Accessed: 03 March 2025)

7. O’Scanaill, P. et al. (2018) ‘Single-shot pectoral plane (PECs I and PECs II) blocks versus continuous local anaesthetic infusion analgesia or both after non-ambulatory breast-cancer surgery: a prospective, randomised, double-blind trial’, BJA, 120(4), pp. 846-853. Available at: https://www.bjanaesthesia.org.uk/article/S0007-0912(18)30030-8/fulltext (Accessed: 03 March 2025).

8. Evans, M. T., Wigmore, T. and Kelliher, L. J. S. (2019) ‘The impact of anaesthetic technique upon outcome in oncological surgery’, BJA Education, 19(1), pp. 14-20. Available at: https://www.bjaed.org/article/S2058-5349(18)30119-7/fulltext (Accessed: 03 March 2025).

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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