Anesthesia for LD Flap Excision and PMMC Reconstruction

A 49-year-old female with left breast carcinoma, previously treated with chemotherapy and palliative radiotherapy, presented with lung and skeletal metastases. She had undergone a left modified radical mastectomy with latissimus dorsi (LD) flap closure and skin grafting. Due to flap necrosis, she was now scheduled for flap excision and pectoralis major myocutaneous (PMMC) flap reconstruction. Anesthetic care in this patient required consideration of her oncologic background, prior treatment-related organ compromise, nutritional status, and perioperative factors influencing flap viability.

Preoperative AssessmentOverall Health Review

The patient appeared cachectic but had normal serum albumin and normal baseline laboratory values. Prior chemotherapy and radiation may reduce cardiopulmonary reserve, while the presence of skeletal metastases increases the risk of fracture during positioning.

References:

Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J. 2010;9:69.

Lally BE, et al. Radiation pneumonitis in breast cancer patients: a review. Int J Radiat Oncol Biol Phys. 2005;63(2):293-302.

Airway and Venous Access

Airway evaluation revealed no compromise despite prior chest irradiation. A central venous line was inserted through the right internal jugular vein to avoid the irradiated left side and to provide reliable access for drug infusion and fluid management.

References:

Biffi R, et al. Central venous access devices in oncology: a review of techniques and complications. Ann Oncol. 1997;8(8):731-740.

van Geffen GJ, et al. Airway management in patients with mediastinal masses: a review. J Clin Anesth. 2008;20(2):159–64.

Intraoperative Anesthesia ApproachInduction and Maintenance

Induction was performed with glycopyrrolate 0.2 mg, midazolam 1 mg, propofol 40 mg, and succinylcholine 50 mg to facilitate tracheal intubation. Maintenance anesthesia was provided using sevoflurane. Muscle relaxation was achieved with atracurium, given as a 30 mg bolus and supplemented with 20 mg hourly.

References:

Barash PG, Cullen BF, Stoelting RK. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.

Martyn JAJ, et al. Succinylcholine-induced hyperkalemia in acquired pathologic states. Anesthesiology. 2006;104(1):158–69.

Adjunctive Agents

Dexmedetomidine (20 mcg) was used to provide sedation and reduce opioid requirements. Magnesium sulfate (2 mL in 100 mL solution) was administered for its NMDA receptor antagonism and analgesic-sparing effect. Diclofenac suppository was given for postoperative analgesia. Paracetamol was withheld in accordance with the surgical team’s protocol.

References:

Goyal R, Singh S. Perioperative dexmedetomidine in cancer surgeries: potential role and rationale. Indian J Anaesth. 2021;65(3):166-70.

Koinig H, et al. Magnesium sulfate reduces intra- and postoperative analgesic requirements. Anesth Analg. 1998;87(1):206–10.

Wesa KM, et al. Safety and effectiveness of non-steroidal anti-inflammatory drugs in cancer pain management. Support Care Cancer. 2006;14(12):1171–80.

Monitoring and Hemodynamics

Standard ASA monitoring was employed throughout the procedure. Hemodynamics remained stable, and central venous access facilitated fluid administration and titration of anesthetic drugs.

Reference:

American Society of Anesthesiologists Task Force. Practice advisory for intraoperative monitoring. Anesthesiology. 2015;122(2):376–86.

Positioning and Ventilation

Gentle supine positioning with careful padding was adopted to minimize the risk of fractures in bones affected by metastases. Lung-protective ventilation was instituted, using reduced tidal volumes in view of pulmonary metastases and possible radiation-induced lung injury.

References:

Hainsworth JD, Greco FA. Pulmonary complications in cancer patients. Curr Opin Pulm Med. 2001;7(4):221–4.

Neto AS, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without ARDS. JAMA. 2012;308(16):1651–9.

Temperature and Flap Perfusion

Perioperative hypothermia was avoided using warming blankets. Maintenance of normothermia was considered critical because hypothermia-induced vasoconstriction can compromise blood supply to the flap.

References:

Sessler DI. Perioperative thermoregulation and heat balance. Lancet. 2016;387(10038):2655–64.

Blondeel PN, et al. The importance of perfusion in flap surgery: blood flow analysis in perforator flaps. Plast Reconstr Surg. 2003;112(7):2150–61.

Reversal and Emergence

Neuromuscular blockade was reversed with neostigmine 2.5 mg combined with glycopyrrolate 0.4 mg. Extubation was performed only after ensuring complete neuromuscular recovery.

References:

Naguib M, et al. Neuromuscular monitoring and postoperative residual curarization: a meta-analysis. Br J Anaesth. 2007;98(3):302–16.

Kopman AF, et al. Reversal of neuromuscular blockade: new insights. Curr Opin Anaesthesiol. 2013;26(4):451–7.

Postoperative ConsiderationsPain Management

Adequate pain relief was achieved using NSAIDs and dexmedetomidine infusion, minimizing opioid use. Paracetamol was avoided in line with the surgical team’s decision.

Reference:

Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33(3):160–71.

Flap Monitoring and Respiratory Care

Close monitoring of PMMC flap viability was emphasized. Flap temperature, color, and capillary refill were assessed regularly. Pulmonary care was equally important because of the preexisting lung metastases. Incentive spirometry and chest physiotherapy were encouraged.

References:

Cheng MH, et al. Flap monitoring and salvage of compromised flaps. Plast Reconstr Surg. 2002;110(1):222–7.

Smetana GW. Preoperative pulmonary evaluation. N Engl J Med. 1999;340(12):937–44.

ICU Consideration

Postoperative ICU care was planned based on intraoperative stability and the patient’s oncologic comorbidities. Given her metastatic disease and major flap reconstruction, ICU monitoring was prudent for early detection of flap compromise and respiratory complications.

Reference:

Pearse RM, et al. Mortality after surgery in Europe: a 7-day cohort study. Lancet. 2012;380(9847):1059–65.