Severe Aortic Stenosis and a Fractured Hip at 07:00

Two clocks are running

• Fracture risk is time-dependent: registry and cohort data show 30-day mortality and complication rates climb once hip fracture surgery is delayed past 48 h, with the steepest rise in the oldest and frailest patients. Nine hours is comfortably inside that window.
• Valve risk is fixed and large: severe, symptomatic aortic stenosis (exertional syncope) is a class I indication for valve replacement. Noncardiac surgery in this setting carries a substantial risk of hypotension, myocardial ischemia, and cardiac arrest regardless of anesthetic technique.
• Definitive valve therapy (TAVR or surgical AVR) cannot be delivered in nine hours. Waiting for a complete structural heart work-up converts an acute fracture into weeks of immobility, delirium, pressure injury, and VTE - each with its own mortality.

The middle path Proceed within 24 h with a hemodynamically tailored plan, while simultaneously referring to the structural heart team so that post-operative evaluation begins immediately. Do not promise the family that any technique makes the valve safe; the plan reduces rather than eliminates risk. Escalation triggers before incision: chest pain, syncope, new dyspnea, or pulmonary edema - any of these should pause the case for cardiology input. If the hospital lacks TEE and post-operative critical care capability, transfer to a centre that has both is a legitimate alternative to operating locally.

Neither technique has been shown superior in severe AS; the hemodynamic insult matters more than the label.

The physiology to protect: a hypertrophied, poorly compliant left ventricle that is preload-dependent, needs atrial systole, and is exquisitely sensitive to loss of systemic vascular resistance. Coronary perfusion occurs in diastole, so tachycardia both shortens filling time and reduces coronary driving pressure.

• If neuraxial: a dense, high block produces an abrupt sympathectomy that this patient cannot compensate for. Use a low-dose, incremental technique - for example isobaric bupivacaine 7.5–10 mg with intrathecal fentanyl 15–25 mcg - accept a sensory level around T10, and start a phenylephrine infusion (0.3–0.5 mcg/kg/min) before the block is placed rather than chasing a fall.
• If general: invasive arterial monitoring before induction, slow titration of etomidate or propofol, maintenance with an agent that preserves contractility, and vasopressors (norepinephrine or vasopressin) immediately available. General anesthesia has the advantage of allowing TEE if a probe and expertise exist.
• Targets either way: heart rate 60–80 in sinus rhythm, MAP within 20% of the 138/70 baseline, no fluid boluses that produce pulmonary edema and no nitrous oxide-related distension if bowel handling is expected.

Ask the daughter's question directly: she is not wrong that a spinal worked before - the difference is that the previous anesthetic was not delivered to a fixed-output ventricle.

Disposition: a monitored bed with continuous ECG and arterial pressure for at least 24 h, not a general ward. Severe AS plus major orthopedic surgery plus the residual sympathectomy or anesthetics justify intensive or high-dependency care.

Analgesia - opioid-sparing and block-based

• A fascia iliaca or pericapsular nerve group block with a catheter reduces systemic opioid requirement and enables sitting out of bed.
• Scheduled acetaminophen; avoid NSAIDs (creatinine 1.4, risk of fluid retention and renal injury in a preload-dependent ventricle).
• Reserve parenteral opioids for breakthrough, given in small increments with continuous oximetry and sedation scoring, because this patient will desaturate before she becomes tachypneic.

Specific surveillance

• Hypotension: treat with vasopressor and cautious volume, not large crystalloid boluses.
• Tachycardia or new atrial fibrillation: both are poorly tolerated; restore sinus rhythm rather than simply rate-controlling.
• Anemia: transfuse to keep hemoglobin above a threshold that maintains oxygen delivery (generally 8 g/dL, higher with ischemic symptoms).
• Delirium: continue metoprolol, avoid benzodiazepines and anticholinergics, mobilize day one.
• Ischemia: a 12-lead ECG and troponin on the first two mornings, recognizing that a rise does not automatically mandate catheterization in a patient awaiting valve replacement.