Pain Management following Breast Surgery - part 2

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Pathway for post op drain management (all cases excluding LD flap reconstruction).

Post-op Drain Management

Pain

The following prescription is to be standard for all breast operations.

Stage 1. Preoperative

  • Regular Paracetamol 1g QDS orally
  • PRN Oramorph 5-10mg every 4 hours
  • PRN Cyclizine 50mg


Stage 2. Intraoperative:

Induction:

  • 8mg dexamethasone
  • Paracetamol 1G IV
  • Ketamine 1-2ml/Kg as bolus
  • 10mg intramuscular morphine as depot analgesic prior to incision


During surgery:

  • Use of entropy allowing titration of propofol-based analgesia
  • Top up doses of fentanyl
  • 20mg ketorolac in absence of contraindication
  • Ondansetron 4mg prior to end of procedure
  • Chirocaine 40cc 0.375% + adrenaline (1:200,000) + clonidine 1mg/Kg total dose administered as infiltration around drain site and surgical wound site
  • LD flap reconstruction: placing of arrow epidural catheter as intrapleural catheter under direct vision – bolus of 20cc 0.25% chirocaine followed by syringe driver infusion of 5ml/hr chirocaine 0.25% + adrenaline (1:200,000)

 

Stage 3. Post-operative:

  • Fragmin 2500/5000u SC at 2-4 hours in absence of bleeding prior to discharge
  • If pain controlled at 6 hours and drains <150ml total suitable for discharge with paracetamol +- ibuprofen if appropriate 200-400mg QDS as TTO
  • If pain uncontrolled at 6 hours despite PRN oromorph add Tramadol 50mg TDS PO and include on TTO
  • Review pain at 8am Day 1: if suitable for discharge prescribe paracetamol +- ibuprofen + tramadol 50mg PRN as TTO

Post-op Process

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