Background and Aims We present the management of an elderly ASA 4 female with a left-sided fractured neck of femur. Comorbidities included stable angina, asthma and COPD. Acutely, a superimposed chest infection precipitated respiratory distress and hypoxaemia. Clopidogrel, stopped the day before, precluded neuraxial anaesthesia. The patient‘s Surgical Outcome Risk Tool score for mortality within 30 days was 15%. Following multi-disciplinary input, a decision to operate under regional anaesthesia was made.

Methods The femoral, obturator, lateral cutaneous femoral nerve and sciatic nerves were successfully blocked, and a dynamic hip screw was inserted with minimal risk to the patient. The patient followed an uncomplicated intraoperative course.

Results Post-operatively, the patient remained comfortable. Following a period of transnasal humidified rapid-insufflation ventilatory exchange in recovery and intensive care review, the patient was transferred to the ward under the joint care of the orthogeriatricians and orthopaedics. She remained comfortable on oral analgesics on review the following day.

Conclusions This case demonstrates that NOF surgery can be done under peripheral nerve blockade only. It is apparent to us that there may be several subsets of high risk patients in whom this strategy is preferable to central neuraxial blockade or general anaesthesia, and we expect this to become increasingly common in the future.