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Background and Aims With the population ageing, the incidence of fractures and thus orthopaedic surgeries among the elderly is increasing. These patients are often frail, making their perioperative management challenging, as this case aims to illustrate.

Methods An 81-year-old female patient, ASA IV, with history of severe left ventricular dysfunction &noentity65533;LVD&noentity65533; (ejection fraction of 29%) was admitted with a subcapital femur fracture, proposed for surgery. Upon arrival to the operating room, a sinus bradycardia &noentity65533;(52bpm) and a mean arterial pressure &noentity65533;MAP&noentity65533; of 100mmHg were noted. An arterial line was placed and an ultrasound-guided suprainguinal fascia iliaca nerve block was performed (Ropivacaine 0,375%, 75mg) followed by a spinal block (Bupivacaine 0,5%, 7,5mg and Sufentanil 2,5μg). Five minutes later, MAP dropped &noentity65533;(65mmHg) and a bolus of Phenylephrine 100μg was administered, successfully. To maintain adequate MAP, a Phenylephrine perfusion was initiated. For sedation, a Dexmedetomidine perfusion was started. Intra and postoperative periods were uneventful.

Results In this patient, under beta-blocker therapy and with severe LVD, maintaining an adequate MAP and heart rate is essential. A spinal block complemented by an analgesic nerve block is an effective technique. However, due to reduced peripheral vascular resistance and absence of compensatory mechanisms, a Phenylephrine perfusion was required. Sedation was performed considering intraoperative environment and patient request.

Conclusions In frail patients, the use of reduced local anaesthetic doses and the combination of regional techniques decrease anaesthetic risks, improving surgical outcomes. These strategies enhance the safety of anaesthesia, emphasising the importance of customised approaches to ensure successful outcomes in the elderly.