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Background and Aims 79 years old female with Severe Copd with Fev1 of 0.9 l and Fev1/FVC 50%, Severe Aortic stenosis,40 pack year smoking history of 20/day and limited mobility due to breathlessness after 10 yards. Spirometry revealed severe airflow obstruction. Patient presented with Bilateral shaft of femur fractures, Right Mid shaft comminuted fracture and Left Long spiral femur shaft fracture. Patient needed complex surgery to repair bilateral fractures and duration of surgery > 4 hours with difficult positioning for regional anaesthesia.Methods Patient consented for intrathecal catheter under Ultrasound guidance in view of difficult positioning to facilitate the complex surgery. Locoregional analgesia achieved for Patient in severe pain with Ultrasound and PNS guided Bilateral femoral-sciatic nerve blocks with 0.2% Ropivacaine 25 ml bilateral infiltration. positioning achieved by propping up with support. Ultrasound guidance used to mark the depth of anterior complex, midline and ligamentum flavum. Microcatheter insertion technique through 18 G Epidural needle after loss of resistance at the location marked with Ultrasound. CSA maintained with aliquots of Isobaric 0.5% Levobupivacaine 0.5 ml every 15–20 minutes. Good block level of T 8 bilateral achieved. Dense block and sufficient analgesia throughout surgery lasted 4 hours. Haemodynamic monitoring perioperatively and patient transferred to High Dependency unit for monitoring. Uneventful postoperative period.Results Femoral-Sciatic nerve blocks with USG and PNS guidance are optimum for positioning patient with bilateral femur fractures. CSA is safe and effective technique for operating Bilateral femoral fractures with prolonged duration of surgery in frail and elderly. VAS Pain score reflects excellent analgesia achieved.Abstract EP187 Figure 1USG image with catheter in situAbstract EP187 Figure 2Rt sided femur after retrograde nailingAbstract EP187 Figure 3Left sided femur after nailingConclusions USG guided marking enables microcatheter insertion to initiate CSA in a patient difficult to position bilateral arthroplasty. The titratability of CSA allows haemodynamically stable anaesthesia for Aortic Stenosis. The haemodynamic impact of a carefully titrated CSA has also been shown to be comparable with that of using peripheral nerve blocks.