The patient was sedated overnight with oral diazepam 10 mg and premedicated with another 10 mg diazepam orally just before being transferred to the theater on the morning of operation.
In the preoperative holding area, the patient was connected to a Nellcor Puritan Bernnet multiparameter patient monitor and the baseline vital signs were recorded. The noninvasive blood pressure was 120/80 mmHg, pulse 90 beats/min and peripheral arterial oxygen saturation 97% on room air. A peripheral intravenous access was established and the patient was sedated with intravenous diazepam 2.5 mg and pethidine 50 mg. This was followed by intercostal nerves block on the left side at thoracic levels 2-7, with 4 ml 0.375% bupivacaine with 1:200,000 epinephrine per nerve, using a size-22 gauge quincke spinal needle and the technique described by Brown. The mid-axillary approach was used in the lower three thoracic levels (T5-T7), while the posterior approach was used for the remaining three upper levels (T2-T4) because of the technical difficulties encountered with the former approach due to the size of the patient. The block was supplemented with an infraclavicular infiltration of 5 ml of the same local anesthetic to interrupt the branches of the superficial cervical plexus that provide sensation to the upper part of the breast, and subcutaneous infiltration of another 5 ml in the midline in an “upside down” L-pattern to block those intercostal nerve fibers that cross the midline from the contralateral side. Cialis Jelly
After demonstration of adequate blockade by loss of sensation to pinprick about 15 minutes following placement of the block, the patient was transferred to the operating room. During the surgery, the patient was sedated with intermittent intravenous diazepam and pethidine as required. The doses of these drugs were titrated to ensure a minimally depressed patient who was able to maintain airway independently and responded to verbal command. The anesthetist maintained communication with the patient throughout the surgery. The pulse rate and oxygen saturation monitored continuously, and the noninvasive blood pressure monitored every five minutes using the Nellcor Puritan Bernett multiparameter monitor all remained two hours and were uneventful. Anesthesia was generally effective.
The patient was observed in the recovery room for about one hour before being transferred to the ward. She tolerated oral intake within four hours after the operation. The first dose of postoperative analgesic was given on request about five hours after the surgery. She had an uneventful postoperative course and was discharged home to continue on cytotoxic drugs and cialis professional, while awaiting radiotherapy.