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Background and Aims Patients with critical limb ischemia represent a significant anesthetic challenge due to multiple severe comorbidities, established chronic pain, and use of systemic anticoagulation. These patients often require multiple high-pain procedures and prolonged hospital stays, frequently culminating in lower limb amputation. In this complex clinical setting, peripheral regional anesthesia emerges as a crucial tool, allowing for better pain control, reduced opioid consumption, lower incidence of phantom limb pain, as well as reduced respiratory complications and sepsis.

Methods This case report details the anesthetic management of an 85-year-old patient presenting for transfemoral amputation. The patient had CKD-V under renal replacement therapy, ischemic heart disease with reduced ejection fraction of 23%, COPD, dyslipidemia, type II diabetes, a failed bypass graft under high dose opioid requirements and systemic anticoagulation with LMWH.

Results The patient‘s enoxaparin was suspended 24 hours prior to surgery. A femoral nerve block, sciatic nerve block via transgluteal approach, obturator nerve block via a subpectineal approach, and lateral femoral cutaneous nerve block were successfully performed, and sciatic and femoral catheters were placed. The transfemoral amputation was performed without the need for additional sedoanalgesia. There were no anesthetic or surgical complications. During the procedure, 1 unit of red blood cells and 1 gram of tranexamic acid were administered. The patient remained in the PACU for 48 hours for surveillance with nurse-controlled analgesia, achieving good pain control.

Conclusions Peripheral regional anesthesia provided effective anesthesia and analgesia, and facilitated a complication-free transfemoral amputation in a high-risk patient, demonstrating its effectiveness as an anesthetic approach in complex cases.