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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 90-91
 

Intraoperative fluid management during mastectomy: How we do it!


Department of Anaesthesiology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Abhijit S Nair
Department of Anaesthesiology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_17_18

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How to cite this article:
Nair AS, Naik V, Rayani BK. Intraoperative fluid management during mastectomy: How we do it!. Indian Anaesth Forum 2018;19:90-1

How to cite this URL:
Nair AS, Naik V, Rayani BK. Intraoperative fluid management during mastectomy: How we do it!. Indian Anaesth Forum [serial online] 2018 [cited 2019 Sep 16];19:90-1. Available from: http://www.theiaforum.org/text.asp?2018/19/2/90/245536




Sir,

Patients having breast cancer are advised not to allow blood sample collection, injections, blood pressure (BP) recordings and trauma on the arm of affected/operated side during and after treatment (medical and surgical). This is to reduce the risk of cellulitis and breast cancer related, lymphedema (LE). The chances of developing LE during treatment are increased when there are sentinel lymph node biopsy, axillary lymph node dissection, and axillary lymph node irradiation.[1] BP measurement with a cuff on ipsilateral arm is considered a risk factor for the development of LE after breast cancer treatment due to increased venous pressure while measuring BP.[2] When mastectomy is performed under anesthesia, noninvasive BP is measured and charted every 3–5 min and sometimes more frequently if there is hypertension or hypotension. For this reason, most of the clinicians tie a BP cuff on the contralateral arm. BP cuff on ipsilateral arm can also interfere with surgical site access and draping of axilla, mandating to keep the cuff on the contralateral side. However, the current literature suggests that the association of BP measurement on ipsilateral hand and LE is anecdotal, theoretical and has no evidence-based recommendations.[3],[4]

As the intravenous (IV) access is also secured on the contralateral hand, there is backflow of venous blood in the IV drip set with every BP recording [Figure 1]. This can be avoided by turning off the regulator knob of IV set during every BP measurement which is not practical. if the anesthesiologist or technician in odds ratio forgets to turn the knob off, blood might clot in the drip set which might lead to malfunction of the existing cannula. The pre-existing cannula should be considered precious and handled with care as another IV access needs to be placed on the same hand. Another option is to monitor BP by putting the cuff at the calves. However, systolic BP measured on calf is 15–20 mmHg higher than that measures on the arms.[5]
Figure 1: Backflow of venous blood into drip set due to frequent noninvasive blood pressure recording

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We suggest using an inflatable pressure bag during a mastectomy [Figure 2]. The bag can be inflated to a pressure more than 50 mmHg over the baseline systolic BP and IV knob can be adjusted for the desired drip rate. When BP cuff inflates, the inflated pressure bag maintains a pressure more than the systolic BP and thus prevents backflow of venous blood into the drip set. Once surgery is over, the BP cuff can be retained in the same arm or can be changed over to the ipsilateral arm. We suggest keeping the height of IV fluid <60 cm as it is practiced with transurethral resection of prostate and hysteroscopic surgeries to avoid inadvertent air embolism.
Figure 2: 200 mgHg pressure in pressure bag, i.e., 50 mmHg over baseline blood pressure

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Although this is unlikely as the flow is controlled with the knob. The pressure in bag 50 mmHg over-systolic BP was selected arbitrarily, which needs to be investigated. Till date, we have not seen any extravasation or air embolism due to inflated pressure bag in more than 100 cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cemal Y, Pusic A, Mehrara BJ. Preventative measures for lymphedema: Separating fact from fiction. J Am Coll Surg 2011;213:543-51.  Back to cited text no. 1
    
2.
National Lymphoedema Network. Lymphoedema Risk Reduction Strategies. Available from: http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf. [Last accessed on 2018 Jan 16].  Back to cited text no. 2
    
3.
Ferguson CM, Swaroop MN, Horick N, Skolny MN, Miller CL, Jammallo LS, et al. Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. J Clin Oncol 2016;34:691-8.  Back to cited text no. 3
    
4.
Bryant JR, Hajjar RT, Lumley C, Chaiyasate K. Clinical inquiry-in women who have undergone breast cancer surgery, including lymph node removal, do blood pressure measurements taken in the ipsilateral arm increase the risk of lymphedema? J Okla State Med Assoc 2016;109:529-31.  Back to cited text no. 4
    
5.
Sareen P, Saxena K, Sareen B, Taneja B. Comparison of arm and calf blood pressure. Indian J Anaesth 2012;56:83-5.  Back to cited text no. 5
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