Ultrasound-guided single shot peripheral nerve blocks (PNB) such as erector spinae plane block (ESPB) and pectoral nerve block (PECS I and II) are emerging anesthetic techniques used to provide complete surgical anesthesia without general anesthesia and adequate postoperative analgesia for breast surgeries. Peripheral nerve blocks with sedation could be a better option for breast surgery than general anesthesia in patients with multiple preexisting comorbidities and those refusing general anesthesia. However, an anesthesiologist with optimum knowledge on regional anesthesia and ultrasound experience plays a key factor to the success of doing PNB. Keywords: ESPB, Erector spinae plane block; PECS I and II, pectoral nerve block; breast surgery; mastectomy; breast cancer OBJECTIVE: The two primary purposes of this case report are to present the first mastectomy on an elderly ASA 3 patient inducted under PNB without being converted to general anesthesia in a tertiary hospital and to enlighten the reader on the efficacy of PNB as a sole surgical anesthesia and its use as postoperative analgesia. INTRODUCTION: Breast cancer is known to be the most common cancer in women and surgical management remains a key component of treatment and cure. However, the surgical procedure is often associated with varying degrees of postoperative pain ². 2 Postmastectomy pain syndrome (PMPS) is a complex disorder associated with breast surgeries which limits the normal functionality and affect the overall quality of life ¹. Thus, ultrasound-guided peripheral nerve blocks namely ESPB and PECS I and II blocks emergently play a crucial role in providing complete surgical anesthesia undergoing breast cancer surgery and a favorable postoperative pain control. CASE DISCUSSION: A 73 y.o. 57kg, ASA 3 female admitted for gradually enlarging right breast mass advised for mastectomy. She is known hypertensive for more than 10 years and on a maintenance medication, but noncompliant. Patient had cerebrovascular accident (March 2020) with no residual neurologic deficits. Upon assessment, patient had essentially normal physical examination findings except for the large, hard, mobile, nontender right breast mass with ulcerated posterior portion. Neither nipple discharges nor axillary lymphanadenopathy were noted. Core needle biopsy was done which revealed phyllodes tumor, right. Chest x-ray film showed an enlarged right breast shadow, atherosclerotic aorta and thoracic spondylosis. The rest of the baseline laboratory results are all within normal limit. Patient was successfully inducted under peripheral nerve block in a form of ESPB and PECS I and II blocks supplemented with moderate sedation in a form of propofol (

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