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Background and Aims 85 year female, ASA Class 4, with multiple comorbidities was planned for palliative right mastectomy. She had severe pulmonary hypertension on home oxygen, cardiac resynchronisation therapy, PPM/AICD for sustained VT, Atrial fibrillation, mechanical mitral valve on warfarin, chronic kidney disease stage 4 and diabetes on insulin. She was diagnosed with invasive lobular breast carcinoma in 2019, was deemed high risk for general anaesthesia/surgery and commenced on hormonal therapy. Cancer had now progressed to involve the nipple/skin causing discharge and pain affecting her quality of life. She was referred to the anaesthetic clinic to see if this surgery could be offered under a regional anaesthesia (RA) technique alone.

Methods Patient was seen in clinic by an anaesthetist with her granddaughter and an interpreter. After understanding the risks and benefits of surgery under RA she was keen to proceed. Anaesthetist with appropriate skill set was allocated to the case.

Results The whole team understood the plan and complexity of the case. Ultrasound guided ESP block was performed with 0.5% Ropivacaine and dexamethasone and catheter was inserted. Minimal sedation was used maintaining verbal contact throughout. Patient was very comfortable during surgery and in recovery. She required no opioids in the next 48 hours. She returned to theatre for evacuation of haematoma on day 3 post surgery and the existing ESP catheter was used successfully.

Conclusions Palliative mastectomy was successfully carried out under RA alone in an unwell elderly patient who would otherwise have been denied surgery due to very high predicted risk of complications for GA.