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Background and Aims Regional anesthesia offers significant advantages in managing patients with severe cardiovascular and respiratory comorbidities. However, in patients with hematological disorders, the bleeding risk can be considerable and overcome potential benefits. Balancing the pros and cons is crucial, yet regional anesthesia may still be the best option despite high intrinsic bleeding risks.

Methods A 68-year-old male with lymphoma, presented with pancytopenia (40.000 platelets) and deep cervical adenopathies. His personal history included atrial fibrillation under rivaroxaban, ischemic heart disease with reduced ejection fraction under, and advanced COPD (basal oxygen saturation of 87%, and reliance on long-term domiciliary oxygen therapy). Excisional biopsy was needed to determine the appropriate chemotherapy regimen. An intermediate cervical plexus block was chosen as the anesthetic technique.

Results After multidisciplinary discussion with the immunohemotherapy service and surgical team, oral anticoagulant was interrupted for 48h. Pre-transfusion blood typing was conducted, a pool of platelets was prepared for potential uncontrolled bleeding, basal ROTEM analysis was performed, and 1g of tranexamic acid was administred. An intermediate cervical plexus block was performed, providing effective anesthesia without the need for additional sedation, while maintaining spontaneous ventilation and hemodynamic stability. Surgery was uneventful.

Conclusions Despite the high bleeding risk, regional anesthesia was chosen due to the patient‘s significant pulmonary and cardiovascular comorbidities. This approach was deemed acceptable as it associated with reduced risk of postoperative intubation or major cardiovascular events in predisposed patients. This case underscores the importance of individualized anesthetic strategies in patients with complex medical histories.