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Background and Aims Patients with cardiovascular and respiratory comorbidities present a challenge for anesthesiologists. In this context and in the era of an ever-increasing opioid epidemic, regional anesthesia and analgesia modalities in combination with opioid-sparing conscious sedation techniques with the aim to avoid general anesthesia while at the same time maintaining a high safety profile may be the best multimodal anesthetic approach.

Methods We present a case of a patient scheduled for radical abdominal hysterectomy. Due to many comorbidities, the presence of a month-old persistent cough and the fact that the surgery had to be performed under an extended midline vertical incision, we decided on a combination of segmental epidural anesthesia and conscious sedation. Thoracic epidural was performed, while, before surgical incision, dexmedetomidine, ketamine and lidocaine were administered as an intravenous bolus, followed by a continuous infusion of a mixture of dexmedetomidine, ketamine and lidocaine throughout surgery.

Results During the operation, the patient was relaxed, responsive to verbal commands, maintained spontaneous ventilation and was completely pain-free even during peritoneal traction and enteral manipulation. The surgical procedure was completed uneventfully and epidural analgesia via a PCEA pump was provided postoperatively. The postoperative course was unremarkable and the patient was discharged within a few days.

Conclusions In this case, we supplemented the segmental epidural technique with sedation via a mixture of dexmedetomidine, ketamine and lidocaine, used until now only in patients undergoing surgery under general anesthesia in opioid-sparing protocols. This report highlights the importance of multimodal approaches in the case of demanding procedures in patients with comorbidities.