(0725) Selective Neck Dissection Under Monitored Anesthesia Care for a Patient With Extensive Cardiac Morbidities

Introduction: Patients with heart failure requiring a neck dissection have a particularly increased risk of morbidity and mortality from general anesthesia. Monitored anesthesia care (MAC) combined with regional anesthesia can reduce the need for sedation, anxiolytics, and analgesics, which may minimize the risk of hemodynamic instability.

Methods: We present the case of a 76-year-old male with history of hypertension, diabetes, atrial fibrillation on rivaroxaban, coronary artery disease, and biventricular heart failure with a left ventricular ejection fraction of less than 20%. The patient required a neck dissection for a large right neck metastatic squamous cell carcinoma from a right parietal scalp primary. On preoperative cardiology and anesthesiology assessments, the patient was deemed to be at high risk for general anesthetic complications.

Results: After discussion with the patient and the anesthesia team, the decision was made to proceed with MAC and peripheral nerve block. An ultrasound-guided right superficial cervical plexus nerve block with a mixture of 1% lidocaine and 2% mepivacaine was performed. After receiving dexmedetomidine and midazolam in the operating room, 1% lidocaine with epinephrine was widely injected to the subdermal, subplatysmal, and intramuscular layers. For airway, the patient was placed on BIPAP with close supervision by both the anesthesia and respiratory therapy teams. The patient was placed in the beach chair position at a 30-degree incline with the neck extended a further 10-degrees to allow for optimal pulmonary and upper airway mechanics. The case proceeded without complications and the patient was discharged on postoperative day 2.

Conclusions: We demonstrate that with proper preoperative planning, neck dissection under MAC and regional anesthesia is a viable option for patients with extensive comorbidities. With a mixture of regional blocks, anxiolytics, low-grade sedation, and airway contingency planning, patients can safely tolerate this procedure while simultaneously sparing them risks of general anesthesia.