What is the recommended anesthesia plan for an 84-year-old male (M) patient undergoing a hip long antegrade intramedullary nail procedure for a right hip fracture, with a history of benign prostatic hyperplasia (BPH) on tamsulosin and finasteride, glaucoma on Timolol (timolol maleate) drops, hypothyroidism on levothyroxine, and impaired renal function, who received enoxaparin last night?

Anesthesia Plan for 84M Undergoing Hip Long Antegrade Intramedullary Nail

Spinal anesthesia with peripheral nerve blockade is the recommended anesthesia technique for this 84-year-old male patient undergoing hip fracture repair, unless contraindicated. 1

Patient Assessment

• 84-year-old male with right hip fracture following mechanical fall
• Medical history: BPH (on tamsulosin and finasteride), glaucoma (on timolol), hypothyroidism (on levothyroxine)
• Last dose of enoxaparin at 9pm last night (anticoagulation concern)
• Laboratory: Normal CBC, good electrolytes, mildly reduced eGFR
• ECG: Sinus rhythm with atrial premature complex, borderline T abnormalities in inferior leads

Anesthesia Technique Selection

Primary Plan: Spinal Anesthesia

• Dosing: Lower dose intrathecal bupivacaine (7-8 mg hyperbaric) to reduce hypotension risk 1
• Adjunct: Intrathecal fentanyl 10-15 mcg (preferred over morphine to minimize respiratory depression) 1
• Position: Lateral position with fractured hip dependent to help lateralize anesthetic effect 1
• Timing: Ensure >12 hours since last enoxaparin dose before needle placement (anticoagulation concern)
• Level: Target L3/4 or L4/5 interspace (avoid higher levels which increase hypotension risk) 2

Peripheral Nerve Block

• Fascia iliaca block or femoral nerve block with ultrasound guidance 1
• Dosing: 20-30 ml of 0.25% bupivacaine or 0.2% ropivacaine 1
• Perform prior to positioning for spinal to minimize pain during positioning

Backup Plan: General Anesthesia (if spinal contraindicated)

• Induction: Reduced doses appropriate for elderly - etomidate 0.1-0.15 mg/kg or propofol 0.5-1 mg/kg 1
• Maintenance: Low MAC (0.6-0.8) sevoflurane or desflurane with air/oxygen mixture
• Analgesia: Remifentanil infusion (0.05-0.1 mcg/kg/min) or fentanyl in small boluses (25-50 mcg)
• Airway: Endotracheal intubation with reduced dose of rocuronium (0.4-0.5 mg/kg)
• Ventilation: Lung-protective strategy with tidal volumes 6-7 ml/kg, PEEP 5 cmH2O

Intraoperative Management

Monitoring

• Standard ASA monitors plus:
• Arterial line for beat-to-beat blood pressure monitoring
• Consider BIS monitoring if general anesthesia used
• Temperature monitoring and active warming

Hemodynamic Management

• Target: Maintain MAP within 20% of baseline or >65 mmHg 1
• Fluids: Balanced crystalloid solution (1-2 ml/kg/hr)
• Vasopressors:
  • Phenylephrine infusion (25-50 mcg/min) for spinal-induced hypotension
  • Ephedrine 5-10 mg boluses for bradycardia with hypotension

Medication Considerations

• BPH medications: Continue tamsulosin and finasteride (risk of urinary retention if stopped)
• Timolol: Be aware of potential bradycardia and blunted response to β-agonists
• Levothyroxine: Continue morning of surgery

Postoperative Care

Analgesia Plan

• Multimodal approach: 1
  • Acetaminophen 1g IV q6h (first-line treatment) 1
  • Peripheral nerve catheter if placed
  • Avoid NSAIDs due to renal concerns
  • Limit opioids to breakthrough pain only at reduced doses (25-50% reduction) 1

Monitoring

• Close observation for:
  • Hypotension (especially with tamsulosin)
  • Respiratory depression (age-related risk)
  • Delirium (high risk in elderly hip fracture patients)
  • Urinary retention (BPH history)

Special Considerations

Anticoagulation Management

• Minimum 12 hours since last prophylactic enoxaparin dose before spinal placement
• If spinal contraindicated due to timing, proceed with general anesthesia

BPH Considerations

• Tamsulosin increases risk of intraoperative floppy iris syndrome if eye surgery needed
• Higher risk of urinary retention postoperatively; consider early catheter placement

Renal Function

• Mildly reduced eGFR requires careful medication dosing
• Avoid nephrotoxic agents and maintain adequate hydration

Pitfalls and Caveats

• Avoid high spinal anesthesia levels (L2/3) which significantly increase hypotension risk 2
• Minimal/no sedation with spinal to reduce delirium risk in elderly 1
• Careful positioning to prevent pressure injuries and fracture displacement
• Maintain normothermia as elderly patients are susceptible to hypothermia
• Recent evidence suggests no significant difference in mortality or ambulation outcomes between spinal and general anesthesia 3, but spinal may reduce intraoperative blood loss and thromboembolic events 4

This plan prioritizes hemodynamic stability, adequate pain control with minimal opioids, and early mobilization to optimize outcomes for this elderly patient with hip fracture.