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Application for ESRA Abstract Prizes : I apply as an Anesthesiologist (Aged 35 years old or less)Background and Aims Regional anesthesia is increasingly recognized as a valuable option for high-risk patients undergoing hip surgery. Fascial plane blocks, particularly lumbar and sacral erector spinae plane (ESP) blocks, offer promising hemodynamic stability. We present a single high-risk cardiac patient undergoing hemiarthroplasty who was successfully managed using a novel dynamic needling technique for sacral and lumbar ESP blocks. This approach aims to optimize anesthetic spread while minimizing volume and potential systemic toxicity.Methods An 87-year-old male with severe aortic stenosis, NYHA Class III heart failure, and multiple comorbidities was scheduled for hip hemiarthroplasty. To avoid general and neuraxial anesthesia, we performed a femoral nerve block, sacral ESP block at S2, and a lumbar ESP block at L2 using ultrasound guidance. Crucially, both ESP blocks were executed using a dynamic needling technique: the needle was actively repositioned within the fascial plane during injection to ensure optimal spread while carefully titrating the volume of local anesthetic.Results A total of 35 ml of 0.375% ropivacaine was used across all blocks. The dynamic technique allowed termination of injection upon achieving target dermatomal coverage (T12-S3), reducing unnecessary volume. The patient underwent surgery under light sedation with spontaneous breathing and remained hemodynamically stable throughout. No opioids or vasopressors were required intra- or postoperatively.Abstract P157 Figure 1Sacral ESP block with in-plane technique and caudo-cranial direction. The needle (N) is seen approaching the lateral sacral crest (LSC) before injection between the multifidus muscle (MM) and LSCAbstract P157 Figure 2Sacral ESP block with in-plane technique and caudo cranial direction. Post injection image, note the diffusion of local anesthetic within the fascial plane and lifting of the multifidus muscle. MM: Multifidus muscle, LSC: later sacral crest, TP: trasverse process, LA: local anestheticAbstract P157 Figure 3Lumbar ESP block at L2 with out-of-plane technique. Spread of local anesthetic (LA) is visible around the transverse process (TP) and erector spinae muscle (ESM), indicating fascial plane openingConclusions This case highlights the potential of dynamic needling in fascial plane blocks to optimize anesthetic spread while minimizing volume and reducing the risk of local anesthetic systemic toxicity (LAST). In high-risk patients, this technique may represent a valuable and safer alternative to conventional regional anesthesia approaches. Further studies are warranted to validate its efficacy and reproducibility.