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Regional·CA-2

82 y.o. Hip Fracture: Regional Logic

Foundational orthopedic scenario balancing Neuraxial vs. General anesthesia in the frail elderly with dementia.

The stem

An 82 y.o. female presents for total hip arthroplasty after a fall at home. History of HTN, stable CAD, and mild dementia. Medications include lisinopril and aspirin. She is currently in pain and slightly confused.

Focus

Neuraxial vs. General anesthesia in the elderly, post-operative delirium risks, and management of anticoagulation protocols (ASRA guidelines).

Examination relevance

The daughter wants her 'completely asleep.' How do you respond? Defend your block choice while navigating the ethical nuances of consent in a confused patient.

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Expert sample response

For this frail 82-year-old with dementia, my goal is to provide a 'delirium-sparing' anesthetic that maximizes her post-operative mobility. I will strongly recommend a neuraxial technique—specifically a spinal anesthetic—as it can reduce the incidence of post-operative cognitive dysfunction compared to general anesthesia.

I will address the daughter's concerns by explaining that while her mother will be 'awake' in a medical sense, we will provide light, titrated sedation for her comfort during the procedure. I will obtain consent from her legal proxy given her confusion. For her pain, I will perform a fascia iliaca or PENG block pre-operatively to reduce her opioid requirements, which is critical for preventing further cognitive decline in the elderly. I will emphasize that maintaining stable blood pressures via the spinal is paramount to preventing cardiac complications in this age group.

Full walkthrough

What the Examiner Is Testing

This case tests your evidence-based preference for neuraxial anesthesia in the elderly to reduce post-operative delirium, and your ability to handle the family's request for general anesthesia diplomatically while still doing what's best for the patient. The examiner is watching for both clinical and communication skills.

The Board Trap

The trap is caving to the daughter's request for "complete sleep" and going straight to general anesthesia. GA with volatile agents in an 82-year-old with dementia significantly increases the risk of post-operative cognitive dysfunction and delirium. The second trap is not addressing aspirin as a potential contraindication to neuraxial — though per ASRA guidelines, aspirin alone is not a contraindication to spinal anesthesia.

Walk-Through: How This Case Plays Out

Examiner: The daughter says her mother needs to be "completely asleep." How do you handle this?

Me: I would take the time to explain the recommendation clearly. I'd tell the daughter that a spinal anesthetic is the safer option for her mother specifically because of her age and her dementia — it reduces the risk of confusion and memory problems after surgery, which can be severe and sometimes irreversible in the elderly. I'd explain that her mother won't be aware of what's happening and that we'll give her light sedation for comfort. Consent would come from the daughter as her legal healthcare proxy, since her mother is confused.

Examiner: She's on aspirin. Can you do a spinal?

Me: Yes. Per ASRA guidelines, aspirin alone is not a contraindication to neuraxial anesthesia. The risk of spinal hematoma is not meaningfully elevated by aspirin monotherapy. I'd proceed with the spinal. If she were on Plavix or anticoagulants, that would be a different conversation.

Examiner: Her spinal goes in but the BP drops to 70/40 within 3 minutes. What do you do?

Me: I would push phenylephrine — 100-200 mcg IV bolus immediately. I also want to make sure she's not hypovolemic coming in — hip fracture patients are often volume-depleted from the injury and from poor oral intake. I'd give a small fluid bolus concurrently. If phenylephrine doesn't work, I'd push ephedrine 5-10 mg for mixed alpha and beta support. I'd tilt the table to enhance venous return.

Examiner: What's your pre-op analgesic strategy?

Me: I would perform a PENG block or fascia iliaca block before going to the OR. These blocks reduce pre-operative opioid requirements, which is critical in this patient — opioids cause confusion, constipation, respiratory depression, and increased fall risk in the elderly. A good regional block on the hip reduces her systemic opioid exposure from the time of the fracture through recovery.

Key Phrases That Score Points

  • "Spinal is the delirium-sparing option for this patient — GA with volatiles increases post-operative cognitive dysfunction."
  • "Aspirin alone is not a contraindication to neuraxial per ASRA — I'm proceeding with the spinal."
  • "Consent from her legal proxy — she's confused and cannot consent herself."
  • "PENG block pre-operatively to reduce opioid exposure from the time of injury."
  • "Phenylephrine immediately for spinal hypotension — I had it drawn up before the block."

Why This Case Appears on the Boards

Elderly hip fracture appears frequently because it tests the intersection of anesthetic technique choice, regional technique, informed consent ethics, and geriatric pharmacology. The communication challenge with the family adds a layer that examiners use to test bedside manner alongside clinical decision-making.