Document resource
Background and Aims Hip fracture surgery in elderly frail patients with multiple comorbidities presents an anesthetic challenge. We describe a combined regional technique used to avoid both general anesthesia and high-dose single-shot neuraxial block in a critically ill patient.Methods A 94-year-old male with a left femoral neck fracture was scheduled for hip hemiarthroplasty. Comorbidities included hypertension, atrial flutter, heart failure with preserved ejection fraction, dementia, polymyalgia rheumatica on chronic corticosteroids, and suspected prostate neoplasia. At admission, the patient was in acute heart failure and type 1 respiratory insufficiency due to respiratory infection. To minimize cardiovascular and respiratory compromise, a combined technique was chosen: an ultrasound-guided lumbar plexus block (Shamrock approach) with 20 mL of ropivacaine 0.5%, followed by continuous spinal anesthesia at L3-L4 with 5 mg of bupivacaine and 0.002 µg of sufentanil.Results The initial intrathecal dose provided adequate surgical anesthesia with no need for additional doses or intraoperative opioids. The patient remained stable throughout the procedure, with no significant hemodynamic changes. Surgery proceeded uneventfully.Conclusions This case illustrates the value of combining peripheral and neuraxial techniques to individualize anesthetic management in extremely frail patients. The approach allowed for hemodynamic stability, effective anesthesia, and avoidance of general anesthesia or high-dose spinal in a critically ill nonagenarian.