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Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less)Background and Aims A 98-year-old, 55-kilogram female with a history of hypertension, hypothyroidism and previous segmental mastectomy for HER2+ invasive ductal carcinoma of the right breast presented with recurrent breast cancer, scheduled for total mastectomy with axillary lymphadenectomy. She strongly expressed the decision to not undergo general anesthesia with tracheal intubation for surgery due to several reasons: 1) an active out of operating room ‘do not resuscitate’ and ‘do not intubate’ status (DNR/DNI), 2) concern for prolonged postoperative recovery and delirium, 3) cardiac risks with general anesthesia given her advanced age.Methods To comply with patient preference and avoid the risks of general anesthesia, regional anesthesia was primarily utilized. Given her ‘oldest-old’ age and low weight, the intended local anesthetic volume had to be divided efficiently to cover the targeted lesions for surgery. ( Figure 1) Ultrasound-guided paravertebral blocks were performed at the right T3 and T5 levels to provide T2-T6 dermatomal coverage. A pectoserratus block was added to anesthetize the deep axillary structures. (Figure 1)Results Following the regional anesthetic interventions, intraoperative sedation for patient comfort included low-dose remimazolam, fentanyl, and a propofol infusion ( figure 2). Throughout the 2.5 hour surgery, she maintained spontaneous ventilation with a simple facemask, reported no discomfort, and remained hemodynamically stable. Postoperatively, the sedatives offset quickly and she denied any nausea or pain related symptoms. On postoperative day (POD) 1, the patient continued to recover with no pain, cognition at baseline, and no perioperative complications. She was discharged on POD3.Abstract P189 Figure 1Right breast with the patient’s cancerous lesion sites, depicted as dark red dots. Area shaded in teal: dermatomal coverage from T2 to T6 after the right-sided, paravertebral blocks at T3 and T5. Area shaded in purple: overlapping coverage from pectoserratus block at the 3rd rib, providing additional anesthesia and analgesia to deep axillary structuresAbstract P189 Figure 2Overview of the anesthesia plan delivered for the 98 year-old, geriatric patient undergoing total mastectomy and axillary lymphadenectomyConclusions Combined paravertebral and pectoserratus plane blocks can be an effective primary anesthetic and postoperative analgesic for a high-risk, geriatric patient undergoing breast cancer resection. Sedation can accompany the nerve blocks to reduce anxiety and help the patient lay still for optimal operating conditions; choosing short acting options can reduce the chances of postoperative delirium in this high-risk patient population.