What analgesic and dose is suitable for an 86-year-old female with a left hip fracture, on Eliquis (apixaban), weighing 54 kg, with hypertension, normal pulse, and mild hypoxemia on 2 L of oxygen?

Analgesic Management for Elderly Patient with Hip Fracture on Apixaban

For an 86-year-old female with a hip fracture who is on Eliquis (apixaban), intravenous paracetamol (acetaminophen) 540-810 mg (10-15 mg/kg based on 54 kg weight) every 6 hours should be administered as first-line analgesia, combined with an ultrasound-guided femoral nerve block to provide effective pain relief while minimizing bleeding risk.

Initial Pain Management Strategy

First-line Analgesic:

• Intravenous paracetamol (acetaminophen):
  • Loading dose: 810-1080 mg (15-20 mg/kg based on 54 kg) 1
  • Maintenance: 540-810 mg (10-15 mg/kg) every 6 hours 1
  • Maximum daily dose: 3240 mg (60 mg/kg) for elderly patients 1

Regional Anesthesia:

• Ultrasound-guided femoral nerve block (US-FNB) is strongly recommended as it:
  • Provides superior pain relief compared to conventional analgesia 2
  • Has not been associated with increased bleeding risk in patients on anti-Xa DOACs like apixaban 2
  • Significantly reduces opioid requirements (73.7% reduction compared to conventional analgesia) 2

Rationale for This Approach

Why Paracetamol:

• First-choice analgesic for elderly patients with comorbidities 3
• Well-tolerated at recommended doses with minimal cardiovascular, renal, and hepatic effects 3
• Suitable for short-term use in elderly patients without routine dose reduction 3

Why Avoid NSAIDs:

• High risk of bleeding complications in patients on anticoagulants 1
• Increased risk of renal toxicity in elderly patients 1
• Potential for cardiovascular complications in patients with hypertension (BP 150/72) 1

Why Minimize Opioids:

• Increased risk of respiratory depression in elderly patients with mild hypoxemia (95% on 2L oxygen) 1
• Higher risk of postoperative confusion in elderly patients 1
• Constipating and emetic effects particularly problematic in elderly 1

Opioid Rescue Strategy (if needed)

If breakthrough pain occurs despite paracetamol and nerve block:

• Fentanyl: 27-54 mcg (0.5-1.0 mcg/kg) IV, titrated to effect 1
• Preferred over morphine due to:
  • Shorter half-life
  • Less risk of respiratory depression
  • Lower risk of cognitive dysfunction 1

Monitoring Requirements

• Continuous pulse oximetry given mild hypoxemia
• Regular blood pressure monitoring due to hypertension
• Pain assessment as part of routine postoperative observations 1
• Monitor for signs of bleeding due to apixaban use
• Supplemental oxygen should be continued for at least 24 hours postoperatively 1

Important Considerations

• Timing of surgery relative to last apixaban dose is critical
• Avoid codeine completely due to constipation, emesis, and cognitive dysfunction risks 1
• Ensure adequate hydration to maintain renal function and blood pressure
• Consider individualized dose reduction only if patient has decompensated cirrhosis or advanced kidney failure 3
• Spontaneous retroperitoneal hemorrhage is a rare but serious complication of apixaban that can present with hip pain 4 - monitor for progressive anemia or hemodynamic instability

This approach provides effective analgesia while minimizing risks in this elderly patient on anticoagulation with a hip fracture.