Background:Regional scalp anesthesia is an appropriate choice for regional excision of BCC. When the LA is combined with dexmedetomidine, it can provide sedation, analgesia and hemodynamic stability.  We report a case of surgical excision of a giant BCC under scalp block anesthesia to a high risk patient with dexmedetomidine as an additive to local anesthetics.

Case Report:A 95-year old patient underwent BCC scalp excision surgery. He had a history of COPD, CAD, paroxysmal AF, HTN, monocular, BPH, METS<3. Standard monitoring, IBP, Et CO2 were applied. Goals of anesthesia were to provide sedation, anxiolysis and optimal analgesia without disturbing hemodynamic status and respiratory function. The supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, greater occipital, and lesser occipital nerves were blocked with a total volume of 20 ml lidocaine 1% and 20ml ropivacaine 0.75% plus 1mcg/kg dexmedetomidine (70mcg) equally injected in the aforementioned points. Sensory block was established successfully at 10 minutes. Without administration of other drugs, the 180 min surgery was carried out under mild to moderate sedation (Ramsay score -2 to -3 points) with the patient hemodynamic stable and no complaint of pain or dissatisfaction. He was discharged from PACU with an Aldrete Score of 9. Analgesia endured 20 hours and no signs of delirium occurred.

Discussion:BCC is a skin cancer, which often appears on scalp and rarely may grow to dimensions larger than 5 cm. Managing an elderly high risk patient with PNB is of high importance since benefits outweigh risks. Scalp block can be used as an adjunct to general anesthesia or serve as the main anesthetic method. Dexmedetomidine is a selective a2-adrenoreceptor agonist that offers sedation and analgesia and when mixed with a LA it can prolong duration of block. Peripheral infiltration of 1mcg/kg can provide optimal balance between block features and systemic effects while avoiding adverse events of bradycardia and hypotension. Furthermore, following this anesthetic plan a potential admission in the ICU can be avoided and a high risk patient can be managed as a day case. 

Learning points:This case shows that scalp block is a safe and cost effective choice of anesthesia for extensive skin lesions in high risk patients. The additive of 1mcg/kg dexmedetomidine to LA can augment analgesia, prolong action of LA and achieve sedation with hemodynamic stability without apnea and delirium events.

10 / Case report: Scalp Block with dexmedetomidine as an additive to local anesthetics for Basal Cell Carcinoma (BCC) surgery to a high risk patient