A 60-year-old postmenopausal woman presented with 10 months history of painless left breast mass that increased rapidly in size three months prior to presentation. There was an associated productive cough, which subsided with cough mixture. Patient was a known hypertensive on, moduretic and canadian atenolol. There was no history of previous surgery. Family and social history was not contributory. Physical examination revealed a middle-aged woman who weighed 63 kg. Her pulse was 96 beats/min, full, regular and blood pressure was 140/90. Respiratory rate was 22 cycles/min. The chest was clinically clear with good air entry bilaterally. She had an enlarged firm left breast with inverted nipple and peau d’orange skin change. There was associated ipsilateral non-tender, matted axillary lymph nodes and a few discrete, firm, nontender contralateral axillary lymph node enlargements. Hematological and serum biochemistry results were essentially normal. However, radiological examination of the chest showed widespread cannon-ball metastasis in both lung fields (Figure 3). Abdominal ultrasound showed stones in the gall bladder but no evidence of metastasis in the liver. Electrocardiogram (ECG) showed left atrial enlargement. FNAC of the left breast mass and ipsilateral axillary lymph node was positive for malignant cells.
A diagnosis of stage-IV carcinoma of left breast with pulmonary metastasis was made. Patient was commenced on daily oral dose of tamoxifen 20 g as an outpatient, and scheduled for palliative simple mastectomy. A decision was taken jointly by the anesthetic and surgical teams to employ regional anesthesia with intraoperative sedation. This was discussed with the patient with an assurance of conversion to general anesthesia if necessary. Patient consented to this anesthetic option.
Figure 3. Chest x-ray of case 2 showing metastasis in both lung fields
The patient was sedated overnight with oral diazepam 10 mg and premedicated with another 10 mg orally just before being transferred to the theater on the morning of operation.
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The patient was brought to the preoperative holding area where a Nellcor Puritan Bernett Multiparameter patient monitor was connected and baseline vital signs recorded. The pulse was 88 beats/min, blood pressure was 120/80 mmHg and peripheral arterial oxygen saturation was 96% on room air. A peripheral intravenous access was established and the patient was sedated with intravenous diazepam 2.5 mg and pethidine 50 mg. Using the same technique and drug described for patient 1, intercostal nerves block and infraclavicular and midline subcutaneous local anesthetic infiltrations were performed. Surgical anesthesia was demonstrated within 15 minutes, and the patient was transferred to the operating room. The patient was hemodynamically stable throughout the surgery, which lasted one hour and 15 minutes. Her subsequent postoperative course was uneventful.