Anesthetic Plan for Male Patient Undergoing Bilateral Mastectomy

Pre-operative and Intra-operative Management

The American Society of Anesthesiologists recommends administering paracetamol/acetaminophen pre-operatively or intra-operatively and continuing post-operatively for pain management (Grade B evidence) 1, 2
The American College of Surgeons suggests administering conventional NSAIDs or COX-2 selective inhibitors pre-operatively or intra-operatively and continuing post-operatively for pain management (Grade A/B evidence) 1, 3
Pre-operative gabapentin is recommended to reduce post-operative pain scores and opioid consumption (Grade A evidence) 1, 4
A single intra-operative dose of IV dexamethasone provides both analgesic benefits and reduces post-operative nausea and vomiting (Grade B evidence) 1, 2

The American Society of Regional Anesthesia and Pain Medicine recommends paravertebral block (PVB) as the preferred regional technique for major breast surgery, including bilateral mastectomy (Grade A evidence) 1, 5
PVB provides superior pain control, reduces systemic analgesic consumption, decreases post-operative nausea/vomiting, and may shorten hospital stay 5, 3
If paravertebral block is contraindicated, consider PECS (pectoral nerves) block as an alternative (Grade A evidence) 1, 3
Local anesthetic wound infiltration may be added to regional analgesia techniques for enhanced pain control (Grade A evidence) 1, 2

Continue paracetamol/acetaminophen and NSAIDs/COX-2 inhibitors on a scheduled basis rather than as-needed for consistent pain control 6, 7
Use opioids only as rescue medication when non-opioid analgesics and regional techniques do not provide adequate pain control (Grade B evidence) 1, 3

Nearly 90% of studies evaluating regional analgesia techniques fail to administer basic analgesics (paracetamol, NSAIDs/COX-2 inhibitors, and dexamethasone) optimally 6, 7
Administer paracetamol and NSAIDs/COX-2 inhibitors on a scheduled "round-the-clock" basis rather than "as needed" for optimal effect 6, 7
The combination of paracetamol and NSAIDs/COX-2 inhibitors provides superior pain relief compared to either drug alone 6, 7

For male patients undergoing bilateral mastectomy, implement a comprehensive multimodal analgesic approach including pre-operative gabapentin (Grade A evidence) 1
Intra-operative dexamethasone (Grade B evidence) 1
Paravertebral block performed pre-operatively (Grade A evidence) 1, 5
Scheduled paracetamol and NSAIDs/COX-2 inhibitors throughout the perioperative period 6, 7
Opioids only as rescue medication 1, 3

PVB provides superior postoperative pain control, lowers systemic analgesic consumption, reduces the incidence of nausea/vomiting, and can shorten hospital stay in patients undergoing major breast surgery, including bilateral mastectomy with reconstruction. 8
A continuous paravertebral catheter maintains lower pain scores through postoperative day 5 and improves functional recovery compared with single‑shot techniques. 8
Ultrasound guidance is optional; outcomes are comparable whether the block is performed with or without imaging. 8

In the first 2 hours after surgery, PECS‑2 yields lower pain scores than PVB. 8
After ≈ 18 hours, PVB becomes more effective than PECS‑2 for pain control. 8
PECS‑2 markedly reduces intra‑ and postoperative opioid requirements compared with no regional block. 8
Meta‑analyses demonstrate comparable overall pain relief and opioid consumption between PECS‑2 and PVB, supporting PECS‑2 as a viable alternative. 8

90 % of published clinical trials omitted proper basic multimodal agents, undermining their conclusions; therefore, routine use of these agents is essential. [9][10][11][12][13][14]
Paracetamol and an NSAID or COX‑2 inhibitor should be administered pre‑operatively (or intra‑operatively) and continued post‑operatively on a fixed “round‑the‑clock” schedule, not on an as‑needed basis. [9][10]
The combination of paracetamol + NSAID/COX‑2 provides superior analgesia compared with either drug alone. [9][10]
Omitting the basic analgesic regimen (paracetamol + NSAID/COX‑2) renders regional techniques insufficient for adequate pain control; scheduled dosing is required for consistent relief. [9][10][11][12][13][14]

If no contraindications to PVB exist (e.g., coagulopathy, local infection, patient refusal), perform bilateral continuous paravertebral blocks for complex reconstruction. 8
If PVB is contraindicated, use bilateral PECS‑2 blocks (supported by comparative efficacy data). 8
Add local wound infiltration with a long‑acting local anesthetic to address axillary innervation not reliably covered by PVB or PECS‑2. [no citation – omitted]
Always implement the core multimodal regimen (paracetamol + NSAID/COX‑2, with adjuncts such as dexamethasone and pre‑operative gabapentin when appropriate) as mandated by recent British Journal of Anaesthesia evidence. [9][10]